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Text adapted from Tuggy ML, Garcia J, Newkirk GR (eds): Pocket procedures text in Multimedia primary care procedures, Philadelphia, 2006, Saunders. Illustrations from Rosen R, Chan TC, Vilke GM, Sternbach G: Atlas of emergency procedures, St Louis, 2001, Mosby.
1. ANESTHESIAA. LOCAL ANESTHESIA
 | Key Steps |
1. | Select anesthetic and needle. |
2. | Provide countertraction. |
3. | Infiltrate underneath entire lesion. |
4. | Use field block technique. |
INSTRUCTIONS
1. | Perform local anesthesia with either direct infiltration or a field block. |
2. | Block smaller lesions with direct infiltration. |
3. | Excellent anesthesia may be provided with 1% lidocaine with or without epinephrine. |
4. | Injection using a 27- or 30-gauge needle is well tolerated. |
5. | Buffering the lidocaine with bicarbonate suspension reduces the burning associated with infiltration. |
6. | Applying countertraction to the skin allows for more precise injection into the subcutaneous and dermal layers. |
7. | Depending on the type of incision, extend the area of infiltration at least 2 to 3 mm beyond the incision that has been planned. |
8. | Often the area needs several injections for a full block. |
9. | Perform field blocks by injecting widely around the lesion in a diamond-shaped pattern. |
10. | Pass the needle at 60-degree angles from one side of the lesion. |
11. | Perform the same needle passes on the opposite side to completely surround the area with anesthesia. |
12. | Perform a deep injection below the lesion to ensure that the block is complete in the center of the area. |
INDICATIONS
∙ | Pain relief for procedures |
∙ | Pain relief for trauma or for joint or fracture injection |
∙ | Adjunctive pain relief for steroid injection |
∙ | Diagnostic to assess origin of pain |
CONTRAINDICATIONS
∙ | Injecting into a sterile space through superficially infected area |
∙ | Attempting to anesthetize areas that are large enough that potential toxicity may occur |
CPT AND ICD-9 CODES
B. TOPICAL ANESTHESIA
| Key Steps |
1. | Cleanse area with alcohol. |
2. | Apply topical anesthetic. |
3. | Cover with occlusive dressing. |
4. | Remove cover in 30 minutes to 2 hours. |
INSTRUCTIONS
1. | To obtain topical anesthesia of the skin, first wipe the skin with alcohol to remove the surface oils. |
2. | Apply the topical anesthetic cream to the planned incision area. |
3. | Use 1 to 2 grams of cream to cover a 3-by-3-cm area. |
4. | Cover the area with an occlusive dressing for 30 to 120 minutes depending on the topical agent that is chosen and the desired depth of anesthesia. |
5. | At 30 to 60 minutes, 3-mm depth is usually anesthetized, with an additional 1-mm depth added for every 30 minutes up to 120 minutes total application time. |
6. | Remove the dressing and perform the procedure. |
7. | The skin should show some blanching in the area that is anesthetized. |
8. | For topical anesthesia for mucous membranes, use topical spray lidocaine or benzocaine. |
9. | Apply the spray; onset of action is under 3 minutes. |
10. | Start the procedure at that time. |
C. DIGITAL BLOCK
| Key Steps |
1. | Cleanse digit with antiseptic. |
2. | Inject local anesthesia without epinephrine. |
3. | Inject at 9 to 10 o’clock and at 2 to 3 o’clock. |
4. | Secondary injections. |
INSTRUCTIONS
1. | Perform digital blocks by injecting plain lidocaine alongside the base of the digit from 9 to 10 o’clock and from 2 to 3 o’clock to anesthetize the digital nerves. |
2. | Approximately 1 ml of lidocaine is sufficient to provide adequate anesthesia. |
3. | In some patients, injecting lidocaine toward the palmar surface may be necessary to obtain complete anesthesia of the digit. |
4. | In some instances, as with nail removal, a simple tourniquet from a latex drain may be used to minimize bleeding in the field and retain the injected anesthesia agent in vascular digits. |
INDICATIONS
∙ | Need for local anesthetic that encompasses the digit |
∙ | Ingrown nail removal |
∙ | Drainage of felon or paronychia |
∙ | Management of fracture of phalanx |
CONTRAINDICATIONS
∙ | Use of epinephrine in the anesthetic is contraindicated |
∙ | Patient with hypotension or sepsis leading to peripheral vasoconstriction |
∙ | Coagulation defect (either medication related, congenital, or acquired), relative |
CPT AND ICD-9 CODES
2. BIOPSY TECHNIQUESA. EXCISIONAL SKIN BIOPSY
| Key Steps |
1. | Incise around lesion. |
2. | Excise lesion. |
3. | Undermine skin edges. |
4. | Perform deep layer closure. |
5. | Perform skin closure. |
INSTRUCTIONS
1. | Most lesions require an elliptical excision around the lesion. |
2. | The longitudinal axis of the ellipse should follow the skin lines. |
3. | Excise the skin through the dermis to obtain a full-thickness biopsy. |
4. | Once the ellipse is created, completely remove the tissue sample by severing the underlying subcutaneous attachments. |
5. | To reduce the tension on the wound while it is healing, undermine the tissue along the margins of the excision. |
6. | Use a subcuticular inverted mattress stitch to close the deep layer prior to placing the cutaneous stitches. |
7. | Two or three deep stitches are usually adequate to support the closure of small excisions. |
8. | Deep stitches help to control bleeding and reduce tension on the scar, allowing for improved healing. |
9. | Perform skin closure using nylon suture material that is appropriate for the size of the lesion and location on the body. |
10. | Place simple interrupted sutures to bring the wound edges together to allow healing with minimal scarring. |
11. | Nylon stitches are nonabsorbable and require removal in 5 to 10 days depending on the site. |
12. | Send the specimen for pathologic review. |
INDICATIONS
∙ | Skin lesions that appear to be malignant; it is especially important to leave 1- to 2-mm margins beyond the lesion if attempting to cure |
∙ | Nevi of uncertain malignant potential—acquired, dysplastic, or atypical in appearance |
∙ | Benign growths that cause local irritation (pyogenic granulomas, dermatofibromas) |
∙ | Removal of subcutaneous growths (sebaceous cysts, lipomas) |
CONTRAINDICATIONS
∙ | Local infection at the site of planned biopsy |
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Nonexcisional treatment option available and not yet tried |
∙ | Patient who is unable to comply with wound care |
B. PUNCH BIOPSY
| Key Steps |
1. | Cleanse skin and inject local anesthesia. |
2. | Perform punch biopsy of lesion. |
3. | Sever base of punch. |
4. | Suture or topical hemostasis. |
INSTRUCTIONS
1. | The punch biopsy allows for a full-depth diagnostic sample to be taken from a lesion in a short period of time. |
2. | Clean the area with Betadine solution. (First check for iodine allergy.) |
3. | Then inject 1% lidocaine local anesthetic under the lesion. |
4. | Here use the 2-mm punch biopsy to create a small plug of tissue that you will excise. |
5. | Use a pair of Adson’s forceps to lift the plug, and use iris scissors to sever the base. |
6. | Cauterize the open punch with ferrous subsulfate solution (Monsel’s solution) on a cotton wick or swab. |
7. | Punch biopsy sites larger than 3 mm often require stitch closure on keratinized skin or any site where cosmetic result is more critical, such as the face. |
INDICATIONS
∙ | Skin lesions that appear to be malignant where diagnosis will affect excision of the lesion |
∙ | Nevi of uncertain malignant potential: acquired, dysplastic, or atypical in appearance |
∙ | Rashes where diagnosis is unclear |
∙ | Removal of a small lipoma, which usually requires a large punch biopsy (5 to 6 mm) |
CONTRAINDICATIONS
∙ | Local infection at the site of planned biopsy |
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Nonexcisional treatment option available and not yet tried |
∙ | Patient who is unable to comply with wound care |
C. SHAVE BIOPSY
| Key Steps |
1. | Cleanse skin. |
2. | Apply local anesthesia. |
3. | Shave lesion. |
4. | Topical hemostasis. |
INSTRUCTIONS
1. | Perform the shave biopsy in a clean manner, as complete sterile technique is not required for superficial lesions. |
2. | First, clean the skin with the antiseptic solution. |
3. | Then inject 1% lidocaine to create a wheal at the base of the lesion. |
4. | Whether or not epinephrine is used depends on the anatomic location of the lesion that is to be biopsied. |
5. | Once the lesion has been anesthetized, use a pair of pickups with teeth to raise the lesion and use a 15 blade to shave the lesion off at the dermis. |
6. | To obtain hemostasis, use ferrous subsulfate solution (Monsel’s solution) to chemically cauterize the base of the lesion. |
7. | Use a simple adhesive bandage to cover the biopsy site. |
8. | The procedure is now complete. |
INDICATIONS
∙ | Skin lesions that appear to be benign where cosmetic removal is important |
∙ | Nevi of uncertain malignant potential: acquired, dysplastic, or atypical in appearance; complete excision would be required if the lesion is malignant |
∙ | Rashes where diagnosis is unclear |
∙ | Removal of a small lipoma, usually requiring a large punch biopsy (5 to 6 mm) |
∙ | For diagnosis of potential malignant lesions where punch biopsy is not feasible owing to location |
CONTRAINDICATIONS
∙ | Local infection at the site of planned biopsy |
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Nonexcisional treatment option available and not yet tried |
∙ | Patient who is unable to comply with wound care |
3. SUTURES AND DRESSINGSA. INSTRUMENT TIE
| Key Steps |
1. | Initiate tie with surgeon’s knot. |
2. | Tighten knot so that it lies flat. |
3. | Perform second throw in opposite direction. |
4. | Perform two additional throws to secure knot. |
INSTRUCTIONS
1. | Initiate the instrument tie with a surgeon’s knot. |
2. | Perform it by wrapping the suture around the needle holder twice before grasping the other end of suture and closing the knot. |
3. | When the first tie is completed, perform the next wrap of the suture in the opposite direction around the needle holder. |
4. | Now the knot is locked. |
5. | Perform two or more separate throws to secure the knot in place. |
6. | Alternating knot throws in different directions prevents premature unraveling of the knot. |
INDICATIONS
∙ | Low-tension wound closures |
∙ | Deep closure in confined wound space where manual ties would be difficult |
CONTRAINDICATIONS
∙ | Knots requiring significant tension or sutures applied for hemostasis |
B. INVERTED SUBCUTICULAR STITCHES
| Key Steps |
1. | Initial stitch enters deep. |
2. | Second stitch enters superficially. |
3. | Tie knot in subcutaneous layer. |
4. | Repeat for each stitch. |
INSTRUCTIONS
1. | Use inverted stitches to close deep layers of a wound and allow the knot to be buried in the process. |
2. | The needle tip enters the deeper layer of the subcutaneous tissue and is then brought upward so that it exits the same side more superficially, often in the subcuticular layer. |
3. | Bring the needle to the other side of the wound so that it enters in the superficial aspect of the wound at the same level as the first side. |
4. | Drive the needle deep so that it exits the tissue deep in the wound space where the stitch started. |
5. | Once that is done, tie the knot. |
6. | During the tightening of the knot, pull the wound together with the knot lying deep to the subcuticular layers that are brought together by the stitch. |
7. | Cut the suture short and apply the next stitch elsewhere in the wound to bring about further closure of the wound. |
8. | For small wounds, one or two inverted knots will close the deep layers well. |
INDICATIONS
∙ | High-tension wound closures that require deep-layer closure where knots are preferably buried |
∙ | Wound closures where external suture punctures would be cosmetically unfavorable |
∙ | Wounds that require prolonged support for optimal closure |
∙ | Adjunctive closure with subcuticular running stitches |
CONTRAINDICATIONS
∙ | Knots requiring significant tension or sutures applied for hemostasis |
CPT AND ICD-9 CODES
C. SUBCUTICULAR RUNNING STITCHES
| Key Steps |
1. | Make linear incision under minimal tension. |
2. | Running suture with knot at each end. |
3. | Reinforce with Steri-strips or tissue glue. |
INSTRUCTIONS
1. | Bury subcuticular sutures running horizontal sutures. |
2. | This technique is useful for wounds that are under minimal tension and in which cosmetic results are important. |
3. | It is possible to close deeper wounds with deep sutures of subcutaneous sutures first. |
4. | Begin with a knot beyond one apex of the incision, using polypropylene-coated nylon suture. |
5. | Place the needle through the skin to emerge in the wound. |
6. | Run the suture, taking horizontal bites through the superficial papillary dermis, alternating sides so that the exit point of one side matches the entry point of the other. |
7. | Keep the suture under minimal tension. |
8. | Emerge at the other end beyond the apex and place a second knot. |
9. | Reinforce the wound with Steri-strips or tissue glue. |
INDICATIONS
∙ | Low-tension to moderate-tension wound closures that follow skin lines or wounds partially closed by deeps sutures to support the skin closure |
∙ | Wound closures where external suture punctures would be cosmetically unfavorable |
∙ | Wounds that require prolonged support for optimal closure |
CONTRAINDICATIONS
∙ | Knots requiring significant tension or sutures applied for hemostasis |
CPT AND ICD-9 CODES
D. MATTRESS STITCHES
| Key Steps |
1. | Deeply insert needle 0.5 to 1 cm from wound edge. |
2. | Pass needle deeply across the base of wound. |
3. | Exit opposite side at same distance. |
4. | Reinsert at 0.3 cm from edge on same side of wound. |
5. | Cross wound, exit at same shallow depth, and tie knot. |
INSTRUCTIONS
1. | Mattress sutures are useful in wounds that are under high or moderate tension and where eversion of wound edges is desired. |
2. | Vertical mattress sutures are initially a simple deep interrupted suture, with the needle penetrating the skin 0.5 to 1 cm from the wound edge, depending on the location and size of the wound ( FIGURE AII-1, A). |
3. | Track the suture needle across the wound to 75% of the wound depth, and emerge from the opposite side at the same distance from the skin. |
4. | Reinsert the needle closer to the wound edge, 0.5 to 0.3 cm from the wound, and to 25% of the wound depth, emerging from the opposite side at the same distance from the wound edge. |
5. | Tie the knot, keeping the suture in sufficient tension to close the wound but not strangulate the tissue ( FIGURE AII-1, B). |
6. | Repeat knots about 0.5 to 1 cm apart to close the wound ( FIGURE AII-1, C and D). |
7. | These sutures risk producing cosmetically undesirable marks if left in too long and should be evaluated for removal at 1 week or less, depending on the site. |
INDICATIONS
∙ | Moderate-tension to high-tension wounds |
∙ | Wound closures where external suture punctures would be cosmetically tolerated |
∙ | Wounds that require prolonged support for optimal closure |
∙ | Wounds in areas where inversion of wound edges is more likely (chest, shoulder, thigh) |
CONTRAINDICATIONS
∙ | Wound closures where external suture punctures would be cosmetically unfavorable |
∙ | Cosmetically sensitive areas where the eversion of the wound may lead to thickened scar |
CPT AND ICD-9 CODES
E. TISSUE GLUE
| Key Steps |
1. | Identify appropriate wound type. |
2. | Cleanse and dry wound area. |
3. | Apply three or four layers of tissue glue. |
4. | Dry between each layer to bond skin edges. |
INSTRUCTIONS
1. | Tissue glues are useful for low-tension wound closures or for small wounds that need closure for improved hemostasis. |
2. | First, irrigate, clean, and dry the wound. |
3. | Crush the applicator ampule and allow the adhesive to fill the tip. |
4. | Pinch the wound shut and apply the glue to the surface in three or four layers, allowing for drying between each layer. |
5. | Take care to avoid gluing any unwanted materials or personnel to the patient. |
6. | Once the glue is dry, you may cover the wound or leave it open depending on the site and risk of contamination. |
INDICATIONS
∙ | Superficial lacerations |
∙ | Nail lacerations |
∙ | Superficial closure over deeper tension-reducing sutures |
∙ | Repair of lacerated nails or nail beds |
CONTRAINDICATIONS
∙ | Mucosal lesions |
∙ | Wounds under tension |
∙ | Contaminated lesions |
∙ | Puncture wounds and crush wounds |
∙ | Bite wounds |
∙ | Complex lacerations |
∙ | Lacerations in the axilla |
CPT AND ICD-9 CODES
• | Codes are dependent on lesion size and location |
F. TOPICAL HEMOSTASIS
| Key Steps |
1. | Perform electrocautery. |
2. | Silver nitrate may be used. |
3. | Ferrous subsulfate solution (Monsel’s solution) may be used. |
INSTRUCTIONS
1. | Obtain a topical hemostasis in several ways. |
2. | Use the Hyfrecator or radiofrequency device to cauterize or coagulate the base of superficial or deep excisions. |
3. | Silver nitrate sticks are useful for cauterizing superficial lesions, though they may leave a stain in the dermal layer. |
4. | Ferrous subsulfate solution is an effective topical agent that leaves little residue after its application and is ideal on mucous membranes such as the cervix, vagina, vulva, and penis. |
INDICATIONS
∙ | For bleeding after cutaneous surgery, especially partial-thickness shave or curetted biopsies |
∙ | To treat nail beds after full or partial nail removal |
∙ | To treat mucous membrane biopsy sites of the glans penis, vulva, vagina, and cervix |
CONTRAINDICATIONS
∙ | Allergy to topical agent |
∙ | Heavy bleeding, in which case the agent is usually not effective |
G. UNNA BOOT APPLICATION
| Key Steps |
1. | Apply moistened Unna boot wrap. |
2. | Wrap second layer with elastic wrap. |
3. | Ensure that ankle is at 90 degrees. |
INSTRUCTIONS
1. | Apply the Unna boot in a manner similar to the application of a cast to the lower leg. The Unna boot is much simpler, however, because it requires only two layers. |
2. | Place the Unna boot material directly against the skin, wrapping it on the leg. |
3. | If there are open ulcers or lesions on the foot or lower leg, ensure that the Unna boot covers them well. |
4. | In areas where there are excess amounts of the wrap owing to changes in the wrapping angle, simply fold in the Unna boot material to allow for compensation of these excess segments of the wrap. |
5. | Once the Unna boot is applied, wrap a second layer around the entire Unna boot to secure it. |
6. | Use an elastic wrap material for the second layer. |
7. | Position the ankle at 90 degrees at the conclusion of wrapping. |
8. | The Unna boot will dry slowly over the next 24 hours and provide an occlusive dressing to the lower leg and foot that can be left in place for 5 to 7 days. |
INDICATIONS
∙ | Venous stasis ulcers |
∙ | Post–venous thrombosis ulcers |
∙ | Severe lower-extremity edema with impending ulceration |
CONTRAINDICATIONS
∙ | Current venous thrombosis |
∙ | Current arterial disease |
∙ | Infected ulcers |
∙ | Cellulitis |
∙ | Allergy to components of the Unna boot |
CPT CODES
• | 29580 Unna boot application |
ICD-9 CODES
• | 457.1 Lymphedema |
• | 707.12 Decubitus ulcers, calf |
• | 707.13 Decubitus ulcers, ankle |
4. NEEDLE ASPIRATIONA. BREAST CYST ASPIRATION
| Key Steps |
1. | Cleanse skin and palpate nodule. |
2. | Insert aspiration needle. |
3. | Multiple passes into nodule. |
4. | Apply pressure to site. |
5. | Place aspirate on slide. |
INSTRUCTIONS
1. | The breast nodule is identified by palpation, and the skin is prepped with antiseptic solution. |
2. | Fix the cyst to the chest wall between the operator’s fingers. |
3. | Place the needle into the center of the cyst, and then withdraw the plunger to allow for creation of a vacuum. |
4. | Larger fluid samples can be sent directly to the pathologist. |
5. | If only a small volume of fluid is obtained, express the contents of the syringe onto a slide and fix with cytology fixative. |
6. | A second pass may be performed to gather more material for sampling. |
7. | Apply pressure to the needle insertion site to prevent hematoma formation. |
8. | Spray the contents of the syringe onto a slide. |
9. | Use a second slide to gently layer the specimen. |
10. | Spray cytology fixative onto the slide to prevent drying before fixation. |
11. | Send the specimen to the laboratory for cytology analysis. |
INDICATIONS
∙ | Palpable lump in the breast |
∙ | Treatment of breast cyst |
∙ | Abnormal mammographic findings combine with stereotactic location of biopsy site |
CONTRAINDICATIONS
∙ | Poorly controlled infection over needle site |
∙ | Known malignancy (excisional surgery indicated) |
CPT CODES
• | 88170 Fine needle aspirate (FNA) with or without preparation of smears |
• | 19100 Biopsy of breast, needle (FNA) |
ICD-9 CODES
• | 611.72 Lump or mass in the breast |
• | 217 Benign neoplasm of the breast |
• | 174.9 Malignant neoplasm of breast (female) unspecified |
5. DERMATOLOGYA. SKIN TAG REMOVAL
| Key Steps |
1. | Inject local anesthesia beneath tag. |
2. | Make a sharp excision. |
3. | Cauterize. |
INSTRUCTIONS
1. | Wipe the skin with antiseptic solution. |
2. | Treat skin tags with or without anesthesia depending on patient preference and the size of the tag to be removed. |
3. | Make a small wheal of local anesthetic under each skin tag. |
4. | Grasp the skin tag with a forceps and trim it at the base with iris scissors. |
5. | Cauterize the base of the skin tag with either electrical or chemical cautery methods. |
INDICATIONS
∙ | Symptomatic skin tags in areas of frequent microtrauma, such as the neck line or axilla |
∙ | Diagnostic concerns (diagnostic removal) |
∙ | Cosmetic concerns |
CONTRAINDICATIONS
∙ | Local skin infection |
∙ | Concern for uncontrollable cosmetic result |
CPT CODES
• | 11200 Skin tag removal by excision or destruction 1-15 |
• | 11201 Each additional tag, up to 10, or portion thereof |
ICD-9 CODES
B. WART TREATMENT
| Key Steps |
1. | Perform cryotherapy: 1-second to 3-second freeze. |
2. | Refreeze lesions. |
3. | Use electrocautery method. |
INSTRUCTIONS
1. | Several options may be used to treat warts. |
2. | Cryotherapy offers a rapid method of treatment of superficial warts. |
3. | Cryotherapy is usually effective if the warts are small and the patient either returns for follow-up or continues to use topical medications after the initial treatment. |
4. | Perform cryotherapy using either a cotton swab dipped in liquid nitrogen and applied to the wart or a liquid nitrogen container equipped with a spray tip to apply the liquid nitrogen directly to the wart. |
5. | Spray each wart until the entire wart and a 1-mm margin have frozen to form a white disc. |
6. | Allow this to thaw, and then refreeze it. |
7. | This dual freeze cycle ensures necrosis of the frozen area. |
8. | Wart cryotherapy also may be done with a nitrous oxide cryotherapy unit fitted with a dermal tip. |
9. | Often, paring the wart down to skin level improves success with cryotherapy. |
10. | For persistent or recurrent warts that fail cryotherapy, injecting local anesthetic and using a Hyfrecator to ablate the lesion is an effective way to eradicate the warts. |
INDICATIONS
∙ | Painful, bleeding, or unsightly warts |
∙ | Warts failing to resolve spontaneously (up to 30% of warts disappear without treatment within 6 months) |
∙ | Warts have a negative impact on the patient’s life (e.g., cosmetic issues, employment issues) |
∙ | Warts are growing or multiplying rapidly |
∙ | Patient has concerns about spreading the virus |
CONTRAINDICATIONS
∙ | Poorly controlled local infection, which should be treated prior to the procedure |
∙ | Caution in cosmetically sensitive areas such as face, lip, or eyelid |
CPT CODES
• | 17110 Destruction of warts 1-14 |
• | 17111 Greater than 15 warts |
ICD-9 CODES
• | 078.19 Plantar warts |
• | 078.10 Verruca vulgaris |
• | 078.11 Condyloma acuminata |
C. ABSCESS INCISION AND DRAINAGE
| Key Steps |
1. | Wear eye protection. |
2. | Perform field block. |
3. | Open abscess with incision that follows skin lines. |
4. | Liberate all areas of abscess. |
5. | Abrade surface of abscess wall and clear debris from wound. |
INSTRUCTIONS
1. | Wear eye splash protection. Identify abscess ( FIGURE AII-2, A). |
2. | Perform a field block by inserting the needle at opposite ends of the area to be anesthetized ( FIGURE AII-2, B). |
3. | Pass the needle alongside the edge of this region and then withdraw it while anesthesia is injected. |
4. | Reinsert the needle at 60 to 90 degrees to the initial block at the adjacent aspect of the first injection. |
5. | After the initial half of the block is completed, anesthetize the opposite side to complete a diamond-shaped field block. |
6. | Open abscesses with an incision that follows the skin lines ( FIGURE AII-2, C). |
7. | Use a 15 blade to open the skin and express the material inside the abscess. |
8. | Use hemostats to break open adhesions or abscess pockets and to ensure that all areas of the abscess are liberated ( FIGURE AII-2, D). Irrigate the abscess cavity ( FIGURE AII-2, E). |
9. | A sebaceous abscess has a smooth capsular lining that needs to be stripped out to prevent recurrence. |
10. | Use a curved hemostat to grasp portions of this capsule wall, which may need to be removed piecemeal. |
11. | In lesions that are not actively inflamed, it may be possible to dissect out the entire wall. |
12. | Gauze can be used to abrade the surface of the abscess wall and clear debris from within the wound. |
13. | After draining the abscess and removing or disrupting the sebaceous cyst wall, pack iodoform gauze into the wound and leave it in place for 2 to 3 days ( FIGURE AII-2, F). |
14. | After 2 to 3 days, the wound can be allowed to heal by secondary intention. |
15. | For larger abscesses, repacking may be necessary to prevent premature closure and abscess reformation. |
INDICATIONS
∙ | Abscess formation within the cutaneous layers anywhere on the body |
CONTRAINDICATIONS
∙ | Virtually none, unless the lesion is on the face within the nasolabial triangle and can be treated with warm compresses with a high probability of spontaneous drainage |
CPT CODES
• | 10060 I&D, one abscess |
• | 10061 I&D, multiple or complex abscess |
ICD-9 CODES
• | 682.9 Cellulitis, abscess, NOS |
D. BASAL CELL CURETTAGE AND CAUTERY
| Key Steps |
1. | Mark lesion. |
2. | Inject local anesthesia. |
3. | Cycles of curettage and cautery. |
INSTRUCTIONS
1. | Punch biopsy of a suspicious lesion on the patient’s arm confirmed basal cell carcinoma. |
2. | Mark the lesion with a surgical marker to clearly delineate the extent of the superficial cancer. |
3. | Infiltrate local anesthesia consisting of lidocaine with epinephrine under the lesion. |
4. | Use a curette to scrape the lesion from the skin surface down into the dermal layer. |
5. | As curettage is performed, the operator should be able to sense the softness of the basal cell cancer in contrast to the normal dermal layer. |
6. | Remove all areas of abnormal density tissue. |
7. | Be especially attentive to the area where the punch biopsy was performed and the prior borders from the surgical marker. |
8. | Curette the lesion in every direction, performing cautery between each curettage episode. |
9. | Generally, perform four cycles of curettage and cautery to ensure that the process eradicates any dermal extension of the basal cell cancer. |
10. | Cover the wound with a simple adhesive bandage on completion of the procedure. |
11. | Cure is assured by finding normal skin on follow-up examination. |
INDICATIONS
∙ | Seborrheic and actinic keratoses |
∙ | Basal cell carcinoma |
∙ | Squamous cell carcinoma |
∙ | Condyloma |
∙ | Pyogenic granuloma |
CONTRAINDICATIONS
∙ | Cellulitis and other bacterial infections |
∙ | Lesions that require complete excision for diagnosis or treatment |
∙ | Pacemakers with electrodesiccation |
CPT AND ICD-9 CODES
• | Codes dependent on lesion size and location |
E. LIPOMA REMOVAL
| Key Steps |
1. | Inject anesthesia and make incision. |
2. | Blunt and sharp dissection. |
3. | Extrude lipoma. |
4. | Place drain. |
5. | Close wound. |
INSTRUCTIONS
1. | The majority of lipoma excisions involve small tumors approximately 3 to 5 cm in size located in the subcutaneous tissues of the trunk or extremities. |
2. | Occasionally in practice, one will encounter large lipomas that require excisions done in an operating suite under the general anesthesia to avoid lidocaine toxicity. |
3. | Place the patient under general anesthesia and situate the patient in the right lateral decubitus position. |
4. | Clean the skin with bactericidal solution and make an incision following the skin lines on the left lateral chest wall. |
5. | Use blunt dissection to expose the superficial surface of the lipoma using a hemostat to separate the layers of subcutaneous tissues that can moderately adhere to the surface of the lipoma. |
6. | With larger lesions, more extensive adhesions and subcutaneous fibers may prevent easy extrusion of the tumor. |
7. | After exposing the initial surface of the lipoma, the dissection continues, using both sharp and blunt dissection to liberate the lipoma from the connective tissue strands holding it to the chest wall. |
8. | Once the perimeter of the lipoma is fully palpable, use both sharp and manual dissection techniques to lift the lipoma off of the connective tissue overlying the rib cage. |
9. | After freeing the majority of the lipoma from the adhesions, extrude the mass out of the incision, then lift it to allow sharp dissection of the basal stalk connecting it to the rib cage. |
10. | Once this has been completed, inspect the wound for any active bleeding and cauterize the necessary vessels. |
11. | Irrigate and prepare the space for closure. |
12. | Prior to closing, inject Marcaine local anesthetic into the subcutaneous layer to provide anesthesia for several hours after the procedure. |
13. | There is significant reduction in pain with use of local anesthetic even in patients who are undergoing surgery with general anesthesia to reduce postoperative pain. |
14. | Place two deep sutures of 2-0 Vicryl to tack the subcutaneous layer to the connective tissue overlying the rib cage, closing the potential dead space. |
15. | After removal of a large tumor, place a Penrose drain to prevent accumulation of serous fluid within the potential dead space in the subcutaneous layer. |
16. | Then use a running subcuticular stitch to close the surface layer of skin and hold the Penrose drain in place. |
17. | Cover the wound with a sterile dressing and advise the patient to follow up in 48 hours. |
18. | At the follow-up visit, the patient should have minimal incisional pain, and you should remove the Penrose drain. |
INDICATIONS
∙ | Large, rapidly growing lipoma, where malignant degeneration is possible |
∙ | Lipomas in cosmetically sensitive areas that are visible |
∙ | Uncertain diagnosis of subcutaneous mass |
CONTRAINDICATIONS
∙ | Patient with numerous nonvisible lipomas |
∙ | Local infection at the site of planned excision |
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Nonexcisional treatment option available and not yet tried |
∙ | Patient unable to comply with wound care |
F. INGROWN TOENAIL REMOVAL
| Key Steps |
1. | Anesthetize with digital block. |
2. | Dissect nail. |
3. | Excise nail. |
4. | Ablate nail bed. |
INSTRUCTIONS
1. | Adequately anesthetize the toe with a digital block. |
2. | Then slip a single blade of the curved iris scissors between the nail and the nail plate along the ingrown area. |
3. | If the nail tightly adheres to the matrix, a small hemostat can help to separate these structures. |
4. | Feel a perceptible give when the tip of the scissors has passed the proximal edge of the nail. |
5. | Once this occurs, use a pair of straight mosquito hemostats to grasp the nail. |
6. | With firm pressure holding the nail to the nail plate, carefully roll out the affected edge to extract the ingrown portion of the nail out of its compartment. |
7. | Use bandage scissors to trim off the uplifted nail edge. |
8. | Take care to ensure that the entire portion of the nail segment to be removed has been excised down to the nail bed. |
9. | Phenol ablation is the most common method used to cauterize the nail bed to prevent or retard future growth of the unwanted portion of the nail. |
10. | Form a small plug of cotton by trimming the cotton from the tip of swab and soaking it with phenol. |
11. | Insert the plug into the opening left by the excised nail edge and push it into the nail bed to cauterize the area. |
12. | Once the nail bed has been cauterized, remove the plug. |
13. | Electrosurgical probes have been developed that can ablate the matrix with excellent cosmetic results. |
INDICATIONS
∙ | Onychocryptosis (ingrown nail) |
∙ | Onychomycosis (fungal infection of nail) |
∙ | Chronic, recurrent paronychia (inflammation of the nail fold) |
∙ | Onychogryposis (deformed curved nail) |
∙ | Symptomatic granulation overgrowth of nail fold, especially if recurrent |
∙ | Permanently deformed nails after trauma; nail matrix ablation is often performed at the same time |
CONTRAINDICATIONS
∙ | Noncooperative patient |
∙ | Unstable infection, may require pretreatment with antibiotics |
∙ | Marginal vascular status of digit; may require clarification prior to injection and surgery |
CPT CODES
• | 11730 Nail removal, partial or complete |
• | 11750 Permanent nail removal (matrixectomy), partial or complete |
ICD-9 CODES
• | 703.0 Ingrown toenail |
• | 110.1 Onychomycosis |
6. EYE, EARS, NOSE, THROATA. NASOPHARYNGOSCOPY
| Key Steps |
1. | Apply decongestant and inspect nares. |
2. | Apply topical anesthesia. |
3. | Insert into nasopharynx. |
4. | Inspect larynx. |
5. | Withdraw scope. |
INSTRUCTIONS
1. | The nasopharyngoscope allows the physician to visualize the upper airway precisely in patients who have upper airway complaints. |
2. | For right-hand-dominant persons, the base of the scope with the direction level is held in the right hand, allowing manipulation of the level by the thumb. The dial on the underside of the scope allows for upward and downward movement of the tip of the scope. |
3. | This movement, combined with rotation of the scope, allows for 360-degree viewing of the airway. |
4. | Apply a topical decongestant to allow the nares to open. |
5. | Inspect the nares to determine which side of the nose is the most patent to pass the nasopharyngoscope through for the examination. |
6. | Use the tripod technique to hold the nasopharyngoscope on the face while inserting into the nares to avoid any undue trauma. |
7. | Identify the nasal passage along the floor of the nose, where the scope should be passed to enter the nasopharynx. |
8. | To prepare for the scope insertion, spray the nares with a decongestant solution. |
9. | Then anesthetize the throat with a topical anesthetic, followed by application of the anesthetic into the selected side of the nose for scope passage. |
10. | First, spray the anterior aspect of the nares, then insert the spray tip perpendicular to the plane of the face along the floor of the nose. |
11. | As the patient holds his or her breath, apply the anesthetic to the deep aspect of the nose as the tip is withdrawn. |
12. | Now advance the nasopharyngoscope into the nares and along the floor of the nasal passage. |
13. | The initial structures that are encountered are the palatine tonsils. |
14. | Rotation of the tip of the scope with flexion laterally to approximately 90 degrees allows one to visualize the Eustachian tube openings and Rosenmüller’s fossa. |
15. | After inspection of these surfaces, advance the scope down into the oropharynx. |
16. | The key structures of the oropharynx to inspect are the base of the tongue, the vallecula, and the posterior aspect of the tonsils. |
17. | Having a patient extend the tongue out of the mouth allows one to visualize the vallecula. |
18. | After inspecting the oropharynx, advance the scope into the hypopharynx, where one visualizes the laryngeal structures and vocal cords. |
19. | Here, inspect the true cords and false cords and the overlying soft tissue of the laryngeal cartilage. |
20. | Also inspect the pyriform sinuses on either side of the larynx. |
21. | The vocal cord movement and symmetry are important to document. |
22. | One can see clearly the movement of the arytenoid cartilage as the vocal cords are contracted. |
23. | On finishing the complete inspection, withdraw the scope in neutral position. |
INDICATIONS
∙ | Epistaxis |
∙ | Removal of foreign body |
∙ | Chronic rhinorrhea |
∙ | Chronic cough evaluation |
∙ | Dysphagia |
∙ | Chronic or recurrent sinusitis evaluation |
∙ | Snoring |
∙ | Dysphonia |
CONTRAINDICATIONS
∙ | Epiglottitis |
∙ | Profuse epistaxis |
CPT CODES
IDC-9 CODES
• | 472.0 Rhinitis |
• | 473.9 Sinusitis, chronic |
B. CERUMEN IMPACTION REMOVAL
| Key Steps |
1. | Examine ear canal. |
2. | Select device for irrigation. |
3. | Irrigate until cerumen is released. |
4. | Conduct follow-up examination. |
INSTRUCTIONS
1. | To remove impacted cerumen, one can use a pulsating water device that allows for pressurized water flow to enter the ear canal. |
2. | Inject the water along the sidewall of the ear, gently forcing water around the impacted cerumen. |
3. | Within a few minutes, one can see small fragments of cerumen coming from the ear canal. |
4. | After several minutes of irrigation, the bulk of the cerumen plug is removed. |
5. | Other device options include a 20- to 30-ml syringe with a 16- to 20-gauge IV catheter attached to provide directed water flow into the ear canal. |
6. | Examine the ear after irrigation to ensure that adequate cerumen was removed. |
INDICATIONS
CONTRAINDICATIONS
∙ | Tympanic membrane perforation |
CPT CODES
ICD-9 CODES
7. HAND/DIGITA. RING REMOVAL
| Key Steps |
1. | Perform neurovascular examination. |
2. | Insert tape with hemostat. |
3. | Wind tape proximal to distal. |
4. | Do not compromise arterial supply. |
5. | Pull proximal edge to unwind. |
INSTRUCTIONS
1. | After careful neurovascular exam demonstrates intact sensation and arterial supply, lubricate the finger ( FIGURE AII-3, A). |
2. | Carefully insert spooled suture, umbilical tape, or dental floss under the palmar aspect of the ring with a hemostat ( FIGURE AII-3, B). |
3. | Secure the suture edge to the palm with an adhesive. |
4. | Proceed to wrap the suture firmly around the finger, starting immediately distal to the ring and moving distally. |
5. | Wrap the suture tightly enough to compress the edema without producing any arterial compromise ( FIGURE AII-3, C). |
6. | After relubricating the finger and removing the suture, gently unwind the proximal edge of the suture by pulling distally and circumferentially ( FIGURE AII-3, D and E). |
7. | After removing the ring, repeat the neurovascular exam. |
INDICATIONS
∙ | Distal finger injury with impending swelling of the finger |
∙ | Ring finger with signs of vascular compromise due to compression from the ring |
∙ | Ring made of conductive or magnetic metal in patient undergoing procedure in which such objects pose a threat to the patient or staff |
CONTRAINDICATIONS
∙ | Extensive bony injury or swelling where it is clear that cutting the ring is the only option |
CPT CODES
• | 20670 Superficial removal of constricting metal band |
• | 20680 Deep removal of constricting metal band |
ICD-9 CODES
8. ORTHOPEDICSA. ARTHROCENTESIS—KNEE ASPIRATION
| Key Steps |
1. | Determine best access to effusion. |
2. | Cleanse skin. |
3. | Inject local anesthesia at insertion site. |
4. | Insert needle and aspirate. |
INSTRUCTIONS
1. | The patient is placed in the supine position. |
2. | The patient’s knee is placed in extension ( FIGURE AII-4, A). |
3. | Carefully clean the skin with an antiseptic solution. |
4. | Identify the patella and palpate to determine the effusion size. |
5. | The ideal location to enter the synovial sac is in the upper outer quadrant of the knee joint space. |
6. | Local anesthetic injected along the planned trajectory of the arthrocentesis reduces the pain of passing the 18-gauge needle through the joint sac. |
7. | Pass the needle through the skin and into the palpable effusion. |
8. | Compress the medial aspect of the knee joint with the opposite hand to push the intraarticular fluid toward the needle and to stabilize the skin for penetration by the needle ( FIGURE AII-4, B). |
9. | Once the fluid space is entered, obtain a sample for diagnostic purposes. |
10. | For tense effusions, withdrawing larger volumes of fluid—up to 50 ml at a time—can reduce pain and improve range of motion. |
11. | After obtaining the desired amount of fluid, withdraw the needle and cover the entry wound. |
INDICATIONS
∙ | Acute joint effusion |
∙ | Acute joint infection |
∙ | Joint pain secondary to large effusion (acute or chronic): therapeutic |
∙ | Gout |
CONTRAINDICATIONS
∙ | Local skin infection at the site of joint |
∙ | Local bursa infection overlying joint |
∙ | Coagulation defect (either medication related, congenital, or acquired), relative |
∙ | Artificial joint |
∙ | Immunosuppressed patient with noninfected joint |
∙ | Sepsis or bacteremia not coming from the joint |
∙ | Unstable joint |
CPT CODES
• | 20610 Arthrocentesis of the knee |
ICD-9 CODES
• | 274.0 Gouty arthropathy |
• | 715.16 DJD knee |
• | 719.45 Knee pain |
B. JOINT INJECTION—SHOULDER
| Key Steps |
1. | Determine injection site. |
2. | Cleanse skin. |
3. | Withdraw joint fluid if effusion present. |
4. | Inject steroid and anesthetic solution. |
INSTRUCTIONS
1. | Cleanse the area over the acromion and upper deltoid to prepare for the injection. |
2. | Maintain sterility during the injection process. |
3. | Identify the space between the acromion and the humerus that is covered by the proximal deltoid attachments. |
4. | Inject local anesthetic in a wheal on the skin, then deeply along the planned injection path into the subacromial bursa. |
5. | Draw up 20 mg of methylprednisolone or its equivalent into a 3-ml syringe and mix with 1 to 2 ml of anesthetic solution. |
6. | Use a 25-gauge needle for injection of the steroid solution. |
7. | Insert the needle into the subacromial space. |
8. | Inject the entire volume of the syringe into the joint space. |
9. | Withdraw the needle and cover the site with a simple adhesive bandage. |
INDICATIONS
∙ | Tendinitis |
∙ | Bursitis |
∙ | Rheumatoid arthritis |
∙ | Osteoarthritis |
∙ | Gout and pseudogout |
∙ | Medical conditions with joint manifestations: inflammatory bowel disease, psoriasis, Reiter’s syndrome (unless associated with human immunodeficiency virus [HIV]), and ankylosing spondylitis |
∙ | Ineffective anti-inflammatory drugs and analgesics |
CONTRAINDICATIONS
∙ | Acute trauma or fracture |
∙ | Metastatic cancer |
∙ | Cellulitis over the injection site |
∙ | Septic periarticular bursa |
∙ | Suspected bacteremia unless the joint is the suspected source |
∙ | Broken skin over the injection point |
∙ | Primary coagulopathy |
∙ | Unstable joints (for steroid injection) |
∙ | Joint prosthesis |
∙ | Anticoagulant therapy |
∙ | Lack of response to two or three prior injections |
CPT CODES
• | 20610 Arthrocentesis of shoulder |
ICD-9 CODES
• | 274.0 Gouty arthritis |
• | 716.91 Arthropathy of shoulder |
• | 727.3 Bursitis, unspecified |
C. JOINT INJECTION—KNEE
| Key Steps |
1. | Determine injection site. |
2. | Cleanse skin. |
3. | Inject local anesthesia. |
4. | Inject steroid solution. |
INSTRUCTIONS
1. | Place the patient in the supine position and place the patient’s knee in extension. |
2. | Carefully clean the skin over the upper outer quadrant with an antiseptic solution. |
3. | Identify the patella and determine the effusion size by palpation. |
4. | The ideal location to enter the synovial sac is in the upper lateral quadrant of the knee joint space, just above the patella. |
5. | Mix a solution of steroid, such as 40 mg of methylprednisolone, with bupivacaine to provide short-term anesthesia within the joint space. |
6. | Pass the needle through the skin and into the joint space. |
7. | With the opposite hand, compress the medial aspect of the knee joint to push the intraarticular fluid toward the needle. |
8. | Drain or partially drain any hemorrhagic effusion that is found. |
9. | After draining the fluid, inject the steroid solution. |
10. | Withdraw the needle and apply pressure to the site. |
11. | Cover the injection site with a simple bandage. |
INDICATIONS
∙ | To rule out septic arthritis |
∙ | To rule out crystal or rheumatoid arthritis |
∙ | Removal of excessive synovial fluid |
∙ | Diagnostic injection of analgesic |
∙ | Therapeutic injection of corticosteroid |
CONTRAINDICATIONS
∙ | Bleeding disorder or excessive anticoagulation |
∙ | Superficial infection or cellulites |
CPT CODES
• | 20610 Injection of joint |
• | May also charge for office visit |
ICD-9 CODES
D. TRIGGER POINT INJECTION
| Key Steps |
1. | Isolate trigger point by palpation. |
2. | Cleanse skin. |
3. | Inject trigger point area. |
4. | Local massage to disseminate injection. |
INSTRUCTIONS
1. | Easily inject painful trigger points with a combination of local anesthetics and steroids to obtain immediate and long-term pain relief. |
2. | Mix 1 ml of bupivacaine with 1.5 ml of lidocaine and the equivalent of 25 mg of hydrocortisone to make up a solution for this injection. |
3. | Precisely identify the trigger point. |
4. | Prep the skin with Betadine or alcohol. (First check for iodine allergy.) |
5. | Insert the needle into the palpable trigger point. |
6. | Inject the solution in 0.5-ml amounts spread over the region that encompasses the entire trigger point area. |
7. | After completing the injection, massage the solution into the surrounding soft tissue. |
8. | Obtain immediate feedback from the patient as the local anesthetics takes effect. |
INDICATIONS
∙ | Myofascial pain |
∙ | Tension headache due to cervical muscle strain |
∙ | Chronic neck or back pain due to trigger points |
∙ | Fibromyalgia |
CONTRAINDICATIONS
∙ | Infection at site of trigger point |
∙ | Bleeding disorder |
∙ | Allergy to any component of injection |
CPT CODES
• | 20522 Inject trigger point, one or two sites |
• | 20553 Inject trigger points, more than two sites |
ICD-9 CODES
E. LATERAL EPICONDYLE INJECTION
| Key Steps |
1. | Identify focal tenderness over epicondyle. |
2. | Cleanse skin with antiseptic. |
3. | Inject steroid/anesthetic solution. |
4. | Massage injection site. |
INSTRUCTIONS
1. | Place the elbow in flexion and palpate the focally tender area over the lateral epicondyle. |
2. | Site of maximal inflammation should be at the proximal attachment of the extensor tendons of the forearm. |
3. | Cleanse the skin over the epicondyle with an antiseptic solution, maintaining sterility of the injection site. |
4. | The injection should contain 10 mg of triamcinolone acetate or its equivalent, with 0.5 ml of lidocaine and 0.5 ml of bupivacaine. |
5. | Insert the needle down to the bony surface of the epicondyle, then withdraw it back 1 to 2 mm. |
6. | Inject the solution into the area of maximal tenderness and reposition the needle slightly in all directions around this area to distribute the medication into a 1.5- to-2-cm diameter area. |
7. | Withdraw the needle and massage the area. |
8. | Cover the site with an adhesive bandage if there is bleeding from the injection. |
INDICATIONS
CONTRAINDICATIONS
∙ | Infection of skin over epicondyle |
CPT CODES
• | 20605 Infection of joint |
• | May also charge for office visit |
ICD-9 CODES
• | 726.32 Lateral epicondylitis |
9. GASTROENTEROLOGYA. ANOSCOPY
| Key Steps |
1. | Inspect anus. |
2. | Insert anoscope. |
3. | Remove obturator. |
4. | Inspect anorectal mucosa while withdrawing scope. |
5. | Rotate 90 degrees, reinsert, and inspect. |
INSTRUCTIONS
1. | The patient is placed in a lateral decubitus position with knees flexed upward toward the chest ( FIGURE AII-5, A). |
2. | Hold the buttocks apart. |
3. | Perform a digital exam, allowing for palpation of the anal canal to check for tone, masses, or areas of unusual pain. |
4. | Lubricate the anoscope with its central guide plug, then slowly insert it past the anal sphincters ( FIGURE AII-5, B). |
5. | Once the scope is inserted completely, remove the central guide plug for inspection of the distal rectum and the anus ( FIGURE AII-5, C and D). |
6. | Slowly rotate the scope as it is withdrawn to maximize viewing of the mucosa above and below the pectinate line. |
7. | The operator should be evaluating the mucosa for the presence of mass lesions or hemorrhoids that may be within view ( FIGURE AII-5, E). |
8. | Masses or polyps that are visible through the scope can be biopsied using a small biopsy forceps. |
INDICATIONS
∙ | Suspected anorectal malignancy |
∙ | Rectal bleeding |
∙ | Hemorrhoid evaluation |
∙ | Perianal condyloma |
∙ | Anal trauma or foreign body, including sexual assault |
∙ | Rectal prolapse |
∙ | Anorectal pain |
CONTRAINDICATIONS
∙ | Anal canal stenosis or congenital imperforate anus |
∙ | Acute cardiorespiratory compromise |
CPT CODES
• | 46600 Diagnostic |
• | 46606 Biopsy, single or multiple |
• | 46900 Destruction of lesion (e.g., condylomata), chemical |
• | 46910 Destruction of lesions, electrodessication |
ICD-9 CODES
• | 455.0 Internal hemorrhoids |
• | 455.2 Internal hemorrhoids, bleeding |
• | 455.3 External hemorrhoid |
• | 565.0 Anal fissure |
• | 569.0 Anal polyp |
• | 698.0 Pruritus ani |
B. FLEXIBLE SIGMOIDOSCOPY
| Key Steps |
1. | Insert scope. |
2. | Advance up the sigmoid. |
3. | Inspect colon while exiting. |
4. | Examine rectal vault. |
INSTRUCTIONS
1. | Anoscopy should be performed in all cases in which palpable abnormality is identified. |
2. | Place the patient in a left lateral position with knees flexed upward toward the chest. |
3. | Initial digital rectal examination assists in identifying anal fissures, polyps, and lesions, as well as allowing for initial application of lubricant. |
4. | Perform anoscopy in all cases in which palpable abnormality is identified. |
5. | Initially advance the scope at an acute angle with the index finger placed behind the advancing tip. |
6. | As the anal canal is entered, gently rotate the scope in line with the anal canal as the scope advances into the rectum. |
7. | Once the scope is inserted approximately 15 cm, insert air to see the rectal vault and find the opening to the lower sigmoid. |
8. | Easily advance the scope up to the most distal turn of the sigmoid. |
9. | After passing around the first curve, the operator may need to use one of several techniques to encourage the straightening of the colon around the scope. |
10. | Once the sigmoid has been traversed, enter the descending colon. |
11. | Here, the colon has a recognizable abundance of rounded haustra. |
12. | Once maximal insertion is achieved, slowly withdraw the scope and inspect the colon walls, using the 360-degree view technique, gradually rotating the scope. |
13. | Take care to inspect behind sharp turns in the sigmoid and behind rectal valves. |
14. | Once the rectum has been inspected, perform retroflexion to view the inside of the anus and lower rectum from above. |
15. | Insert the scope to approximately 15 cm and fully rotate the dials to a near maximal rotation to allow the scope to be fully retroflexed. |
16. | When completed, simple rotation of the shaft of the scope on its axis allows for inspection of the rectum and anus. |
INDICATIONS
∙ | Rectal bleeding of any type |
∙ | Screening for colorectal cancer |
∙ | Persons 50 years of age and older, regardless of symptoms |
∙ | Unexplained anemia |
∙ | Persistent abdominal pain |
∙ | Alteration in bowel habits, constipation (particularly unexplained new onset), diarrhea, altered stool diameter |
∙ | Unexplained weight loss, fever |
∙ | Follow-up of treatment regimens (e.g., for ulcerative colitis, irritable bowel disease) |
For the following conditions, colonoscopy may be preferred as first choice to examine the entire colon in patients with higher risk:∙ | Follow-up for history of polyps or cancer |
∙ | Any person with a high-degree risk factor for cancer or other disease in the colon |
∙ | Hemoccult-positive stools (positive occult blood) |
∙ | Weight loss |
∙ | High suspicion of cancer |
CPT CODES
• | 45330 Sigmoidoscopy, flexible fiberoptic, diagnostic |
• | 45331 Sigmoidoscopy with biopsy |
• | 45336 Sigmoidoscopy with ablation of tumor or mucosal lesion |
ICD-9 CODES
• | 558.9 Colitis, nonspecific |
• | 564.0 Unspecified constipation |
• | 564.1 Irritable colon |
• | 569.3 Anal hemorrhage |
• | 578.1 Melena |
• | 789.0 Abdominal pain |
• | V16.0 Family history of colon cancer |
C. INTERNAL HEMORRHOID BANDING
| Key Steps |
1. | Prepare banding tool. |
2. | Perform anorectal inspection. |
3. | Grasp hemorrhoid with forceps. |
4. | Release band at base of hemorrhoid. |
INSTRUCTIONS
1. | Prior to initiation of the banding procedure, prepare the instruments and load the rubber band on the banding forceps. |
2. | First, place the conical attachment on the banding forceps, slide the rubber band down, and gradually expand it until it fits around the ring portion of the banding forceps. |
3. | Then adjust the rubber band to the distal edge of the banding forceps so that only a small closure of the forceps will allow the release of the band. |
4. | Place the patient in a decubitus position, with knees flexed upward toward the chest. |
5. | Locate the anoscope and insert it into the rectal vault. |
6. | Prior to banding, ascertain that the hemorrhoid is anesthetized and truly is an internal hemorrhoid. |
7. | In most instances, identify internal hemorrhoids by their origin proximal to the dentate (or pectinate) line and the fact that they are not sensitive to simple grasping. |
8. | Insert the grasping forceps through the banding forceps and use it to grasp the body of the hemorrhoid to band. |
9. | Grasp the hemorrhoid and advance the banding forceps forward. |
10. | While squeezing the handle, release the rubber band around the proximal end of the hemorrhoid tissue. |
11. | Painless necrosis of the hemorrhoid will occur within 2 to 3 days, allowing the sloughed tissue to pass in the stool. |
INDICATIONS
∙ | Symptomatic internal hemorrhoids not responsive to conservative therapy |
CONTRAINDICATIONS
∙ | Coagulopathy |
∙ | Anal infection |
∙ | Anal fissure |
∙ | Anal tumor |
∙ | Pregnancy |
CPT CODES
• | 46221 Hemorrhoidectomy by simple ligature, banding |
ICD-9 CODES
• | 455.0 Internal hemorrhoids |
D. EXTERNAL HEMORRHOID EXCISION
| Key Steps |
1. | Cleanse perianal area. |
2. | Inject anesthesia. |
3. | Isolate hemorrhoidal tissue. |
4. | Excise hemorrhoid. |
INSTRUCTIONS
1. | The ideal position for anal surgery is to position the patient on the Ritter table with hip and knees flexed in the “bottoms up” position ( FIGURE AII-6, A and B). |
2. | An acceptable alternative is to place the patient in a left lateral position with knees flexed upward toward the chest and with the buttocks held open by an assistant. |
3. | Clean the anal area with Betadine solution. (First check for iodine allergy.) |
4. | With an acutely thrombosed hemorrhoid, marked tenderness to palpation is common ( FIGURE AII-6, C). |
5. | In this case of a chronic recurrent hemorrhoid, the hemorrhoid is nontender; however, the excision technique is the same. |
6. | Local anesthetic consisting of a combination of lidocaine and bupivacaine provides longer anesthesia and is used to provide a local block ( FIGURE AII-6, D). |
7. | Prior application of topical 20% benzocaine solution can diminish injection site pain. |
8. | Inject the hemorrhoid around all aspects of its base to ensure complete anesthesia. |
9. | Injecting the hemorrhoid itself is not necessary if the base is anesthetized. |
10. | A single, deep injection is also necessary for acute hemorrhoid to allow for extraction of clot within the lesion. |
11. | Once anesthesia is complete and has been allowed to take effect, test the hemorrhoid for sensation. |
12. | Once the hemorrhoid is anesthetized, clamp and stabilize it with hemostats and excise the hemorrhoid across the base of the lesion in an elliptical fashion. |
13. | If there are any visible clots, extract them from the hemorrhoid using the hemostats. |
14. | Usually, there is minimal bleeding in the wound, which can be left open and allowed to drain while it is healing. |
15. | Persistent bleeding may require application of Surgicel or Monsel’s solution. |
16. | Proper cleansing of the area postoperatively is important to ensure minimal likelihood of infection. |
INDICATIONS
∙ | Pain, itching, and burning of thrombosed hemorrhoids |
∙ | Poor hygiene and/or difficult stooling secondary to pain |
∙ | Failure to respond to local therapy such as sitz baths and topicals |
CONTRAINDICATIONS
∙ | Poorly characterized bleeding disorder |
CPT CODES
• | 46083 Incision and drainage of thrombosed hemorrhoids |
ICD-9 CODES
• | 455.3 External hemorrhoids |
• | 455.2.1 External hemorrhoids thrombosed |
E. NASOGASTRIC INTUBATION
| Key Steps |
1. | Determine widest nares for insertion. |
2. | Apply topical anesthetic in nares and throat. |
3. | Insert tube. |
4. | Check placement tube. |
INSTRUCTIONS
1. | Place the patient in a sitting position with the head angled forward in a sniffing posture. |
2. | Apply topical anesthetic either by spray or gel into the nares selected for insertion. |
3. | Anesthetizing the back of the throat can also reduce the risk of vomiting during nasogastric (NG) tube insertion. |
4. | Insert the NG tube along the floor of the nose gently and down the nasopharynx. |
5. | As the tube approaches the larynx and upper esophagus, the patient should tilt his or her head slightly downward to encourage the tube to pass posteriorly into the esophagus. |
6. | Advance the tube to the stomach. |
7. | Test and confirm the tube position by aspiration of gastric contents, which should have a pH of less than 6. |
8. | If the patient is unconscious or sedated, perform a confirmatory x-ray. |
9. | If feeding is planned through the tube, confirm its position by x-ray in all patients. |
INDICATIONS
∙ | Relief of upper gastrointestinal obstruction |
∙ | Drainage of gastric contents, bowel rest |
∙ | Need for tube-delivered nutrition, dye, or medications |
CONTRAINDICATIONS
∙ | Facial fractures involving the nose, maxilla, basal bones of the skull, or suspected cervical spine fracture |
∙ | Unprotected airway in nonresponsive patient |
∙ | Penetrating wound of the neck or chest |
∙ | Nasal obstruction |
∙ | Esophageal obstruction or anomaly |
∙ | Sepsis or bacteremia not coming from the joint |
∙ | Placement of percutaneous endoscopic gastrostomy tube would be more appropriate |
CPT CODES
• | 43752 Nasogastric or orogastric tube placement necessitating physician’s skill |
• | 89130 Gastric intubation and aspiration, diagnostic |
• | 91105 Gastric intubation and aspiration, therapeutic |
ICD-9 CODES
• | 536.2 Vomiting, persistent |
• | 537.0 Gastric outlet obstruction |
• | 560.1 Ileus, paralytic |
• | 561.81 Small bowel obstruction, adhesions |
• | 578.0 Hematemesis |
• | 578.1 Hematochezia |
• | 578.9 GI bleeding, unspecified |
• | 787.01 Vomiting, NOS with nausea |
• | 977.9 Poisoning, unspecified |
10. GYNECOLOGYA. PAP SMEAR
| Key Steps |
1. | Inspect external genitalia. |
2. | Insert speculum. |
3. | Obtain spatula and brush samples. |
4. | Liquid-based Pap smear sampling. |
INSTRUCTIONS
1. | Inspect the external genitalia for lesions, then carefully insert the speculum. |
2. | Advising the patient to relax the perineal musculature can make insertion much less uncomfortable. |
3. | Clearly visualize the cervix. |
4. | Perform the Pap smear in several ways. |
5. | Using a Pap spatula, place the tip of the spatula within the os, and rotate the spatula several times to collect cells on one face. |
6. | When spreading the spatula over a slide, one must take care that the side that is laden with cells is spread over the glass surface. |
7. | The cervical brush obtains excellent endocervical samples. It can be used alone, but use it most often in conjunction with the spatula. |
8. | Commonly use the broom-shaped Pap device with the wet prep and human papillomavirus (HPV) sampling. |
9. | Place the point of the broom within the os and rotate the brush five times to obtain the sample. |
10. | Remove the tip of the brush and place it within the wet prep container. |
11. | Send this sample for both cytology and HPV typing as indicated. |
INDICATIONS
∙ | Women of reproductive age who are sexually active |
∙ | Women who are HIV positive |
∙ | Immunocompromised women |
∙ | During prenatal care workup |
CONTRAINDICATIONS
∙ | Active vaginal, cervical, or uterine infection |
RELATIVE CONTRAINDICATION
∙ | Blood contamination, especially if heavy |
CPT CODES
• | 87621 HPV sampling—Wet prep Pap |
• | 99201-99215 Pap smear and endocervical culture |
ICD-9 CODES
• | 795.00 Abnormal Pap |
• | V25.9 Contraceptive management |
• | V70.0 Well adult exam |
• | V72.31 Gynecologic screening exam |
• | V72.32 Follow up abnormal Pap |
• | V13.29 Personal history other genital system and obstetric disorders |
B. BARTHOLIN’S MARSUPIALIZATION
| Key Steps |
1. | Determine incision site and anesthetize. |
2. | Make incision and remove cyst roof. |
3. | Identify layers for closure. |
4. | Suture with circumferential stitches. |
5. | Complete marsupialization. |
INSTRUCTIONS
1. | The patient is placed in the lithotomy position, and the perineum is washed with antiseptic solution. |
2. | Palpate the cyst manually to clearly identify its size and location. |
3. | Outline the incision with a surgical marker at the junction of the vaginal sidewall and labia minora. |
4. | The incision should be a 2- to 3-cm ellipse whose long axis follows the internal axis of the vaginal side wall, not involving the external labial skin. |
5. | Use a 15-blade scalpel to create the ellipse to be excised. |
6. | Enter the vaginal mucosa followed by careful incision through the fascia overlying the cyst. |
7. | Several layers of fascia and vaginal wall smooth muscles are divided in this process. |
8. | Open these layers sharply until the cyst wall is entered and drainage occurs. |
9. | Once the cyst is entered and drained, excise fully the ellipse of tissue, effectively removing the roof of the cyst adjacent to the vaginal sidewall. |
10. | What remains is the smooth cyst cavity with its distinct edge that must be clearly identified before beginning closure. |
11. | Use a 3-0 Dexon or Vicryl suture to marsupialize the cyst. |
12. | Place the initial stitch by passing the needle through the mucosa and then passing through the cyst wall from the submucosal side to open the remaining portion of the cyst. |
13. | Run the suture continuously around the margin of the incision in small 2- to 3-mm bites. |
14. | Each stitch must take the vaginal mucosa and cyst wall together. |
15. | Once the last stitch is placed, overlapping the initial anchoring stitch, tie the suture securely. |
16. | At the completion of the procedure, one can see that the cyst wall is clearly opened and retracted by the circumferential stitches. |
17. | Immediately postop, the appearance is that of a small cleft on the side where the surgery was performed. |
18. | After several days, the repair is barely noticeable as the vaginal wall further contracts. |
INDICATIONS
∙ | Failed Word catheter treatment in the acute setting |
∙ | Recurrent infections or reaccumulation of Bartholin’s gland cyst fluid |
CONTRAINDICATIONS
∙ | Cysts that could be adequately treated with a Word catheter |
∙ | Coagulation defect (either medication related, congenital, or acquired) that is uncorrected |
∙ | Patient who is unable to comply with wound care |
CPT CODES
• | 56440 Bartholin’s gland cyst marsupialization |
ICD-9 CODES
• | 616.2 Bartholin’s cyst |
• | 616.3 Bartholin’s abscess |
C. BARTHOLIN’S CYST WORD CATHETER PLACEMENT
| Key Steps |
1. | Inject local anesthesia. |
2. | Make incision into abscess. |
3. | Place catheter. |
4. | Inflate balloon. |
INSTRUCTIONS
1. | Place the patient in the lithotomy position and wash the perineum with antiseptic solution. |
2. | Manually palpate the Bartholin’s abscess to clearly identify its size and location ( FIGURE AII-7, A). |
3. | Identify the incision site at the junction of the vaginal mucosa and the labia minora. |
4. | Inject local anesthesia of 1% to 2% lidocaine at the incision site. |
5. | Anesthetize both the skin and deeper fascia overlying the abscess. |
6. | Test the Word catheter to ensure that it will function properly. |
7. | Inject 2 to 3 ml of saline into the catheter port, fill, and inspect the balloon. |
8. | Withdraw the fluid from the catheter prior to insertion. |
9. | Leave the needle in the catheter port to use promptly after inserting the catheter into the abscess. |
10. | Use a 15-blade scalpel to incise the wall overlying the abscess; spontaneous drainage of the abscess will occur ( FIGURE AII-7, B). |
11. | After expressing and draining the entire abscess, insert the Word catheter through the opening ( FIGURE AII-7, C). |
12. | Take care to insert the tip of the catheter fully into the Bartholin’s cyst cavity, not just within the fascia space overlying the cyst. |
13. | Once the tip is in the infected cyst cavity, inflate the balloon with 3 ml of saline and withdraw the needle from the injection port ( FIGURE AII-7, D). |
14. | Apply pressure to the syringe to avoid loss of fluid from the catheter. |
15. | Once the insertion is complete, inspect the area for bleeding. |
16. | Provide the patient with a perineal pad to collect any further drainage that may occur after the procedure. |
17. | Recommend postoperative follow-up in 2 to 3 days to ensure that the catheter placement is appropriate and that the abscess continues to drain. |
18. | Leave the catheter in place for 4 to 6 weeks to induce epithelialization of the cyst and drainage track, preventing further abscess formation. |
INDICATIONS
∙ | Acute infections |
∙ | Pain from cyst enlargement |
∙ | Obstructive Bartholin’s gland cyst affecting the patient’s sexual activity or obstructing the vaginal orifice |
CONTRAINDICATIONS
∙ | Cysts that should be treated by marsupialization |
∙ | Coagulation defect (either medication related, congenital, or acquired) that is uncorrected |
CPT CODES
• | 56420 I&D of Bartholin’s gland cyst |
ICD-9 CODES
• | 616.2 Bartholin’s cyst |
• | 616.3 Bartholin’s abscess |
D. VULVAR BIOPSY
| Key Steps |
1. | Evaluate visible lesions. |
2. | Cleanse skin with antiseptic. |
3. | Infiltrate with local anesthesia. |
4. | Biopsy selected area. |
5. | Perform closure and hemostasis. |
INSTRUCTIONS
1. | Clean the vulva with Betadine solution. (First check for iodine allergy.) |
2. | Inject local anesthetic underneath the biopsy site, allowing it to elevate and provide an ideal platform for a punch biopsy. |
3. | Select a suitably sized punch biopsy to yield a sample through the dermal layer. |
4. | Excise the core of the punch biopsy using iris scissors and small Adson’s forceps. |
5. | If bleeding is minimal, simple application of Monsel’s solution provides adequate hemostasis. |
6. | If bleeding persists, use a single suture of 5-0 chromic or other absorbable suture. |
7. | Submit all samples for pathology. |
INDICATIONS
∙ | Any unidentifiable or concerning lesion |
∙ | Lesion that does not respond to conventional therapy |
∙ | Pigmented lesions |
∙ | Atypical nevi |
∙ | Vulvar ulceration of uncertain etiology |
∙ | Leukoplakia |
∙ | Acetowhite epithelium |
∙ | Vulvodynia with acetowhite epithelium (tissue that turns white after the application of vinegar) |
∙ | Presumed condylomata that are not responding to conventional therapy (following two treatment attempts of any kind) |
∙ | Postmenopausal woman with atrophic vaginitis that does not respond to estrogen therapy and no other cause is evident |
∙ | Any skin abnormality requiring definitive diagnosis |
CONTRAINDICATIONS
∙ | Poorly controlled infection over biopsy site (treat then biopsy) |
∙ | Caution with large excisional biopsies with anticoagulation |
CPT CODES
• | 56605 Biopsy of vulva |
• | 56606 Biopsy of vulva more than one lesion |
• | 56820 Colposcopy of vulva |
• | 56501 Lesion destruction of vulva |
ICD-9 CODES
• | 624.9 Unspecified noninflammatory disorder of vulva and perineum |
• | 078.11 Condyloma acuminatum |
• | 221.2 Benign vulvar neoplasm |
• | 624.8 Vulvar dysplasia |
11. INPATIENT MEDICINEA. LUMBAR PUNCTURE
| Key Steps |
1. | Identify landmarks. |
2. | Inject local anesthetic at insertion site. |
3. | Insert spinal needle into cerebrospinal fluid space. |
4. | Collect cerebrospinal fluid. |
5. | Remove spinal needle. |
INSTRUCTIONS
1. | Place the patient in the flexed lateral decubitus position ( FIGURE AII-8, A). Upright position is also acceptable ( FIGURE AII-8, B). |
2. | Cleanse the skin with antiseptic solution. |
3. | The iliac crest serves as the landmark that marks the interspace between the third and fourth lumbar vertebrae ( FIGURE AII-8, C). |
4. | Place a fenestrated drape over this space after it is marked. |
5. | Anesthetize the skin and deep connective tissue with 1% lidocaine. |
6. | Insert a 21-gauge spinal needle through the interosseous ligament into the intervertebral space. |
7. | Advance the needle toward the umbilicus between the L3 and L4 vertebrae, checking periodically if the physician senses that the needle may have entered the dural space ( FIGURE AII-8, D). |
8. | Usually a “pop” is felt on entering the spinal canal. |
9. | Once the canal is entered, remove the obturator and allow the spinal fluid to flow out into the collection tube. |
10. | Normally, collect three or four tubes with 1 to 3 ml of fluid each and label them sequentially for cerebrospinal fluid (CSF) studies. |
11. | After the collection of fluid is complete, replace the obturator and remove the needle. |
12. | Place an adhesive bandage over the puncture site. |
INDICATIONS
∙ | Suspected meningitis or cerebral infection |
∙ | Evaluation of CSF or pressures for diagnostic purposes (Guillain-Barré syndrome, lupus, multiple sclerosis, pseudotumor cerebri, suspected central nervous system malignancy) |
∙ | Intrathecal or spinal anesthetic |
∙ | Imaging procedures where dye infusion into the CSF is necessary |
CONTRAINDICATIONS
∙ | Local infection at the site of lumbar puncture |
∙ | Coagulation defect (either medication related, congenital, or acquired), relative |
∙ | Suspected increased intracranial pressure |
∙ | Suspected brainstem herniation |
CPT CODES
• | 62270 Spinal puncture, diagnostic |
• | 62272 Spinal puncture, therapeutic for drainage of CSF |
ICD-9 CODES
• | 322.9 Suspected meningitis |
• | 340.00 Multiple sclerosis |
• | 348.2 Pseudotumor cerebri |
• | 357.0 Guillain-Barré syndrome |
• | 710.0 Systemic lupus erythematosus |
• | 852.00 Subarachnoid hemorrhage |
B. SUBCLAVIAN LINES
| Key Steps |
1. | Identify landmarks. |
2. | Inject local anesthesia at insertion site. |
3. | Insert trocar and place wire. |
4. | Exchange trocar for dilator and catheter over wire. |
5. | Suture catheter to skin. |
INSTRUCTIONS
1. | Place the patient in Trendelenburg’s position at about 15 degrees and clean, shave, and drape the skin over the midclavicular region. |
2. | Identify the key landmarks of the midclavicle and the suprasternal notch by palpation. |
3. | Inject local anesthetic along the planned trajectory of the catheter insertion ( FIGURE AII-9, A), notably anesthetizing the periosteum of the clavicle to avoid pain as the insertion needle passes underneath the clavicle. |
4. | Insert the introducer trocar at the midclavicular line and pass it under the clavicle, keeping its tip aiming toward the sternal notch ( FIGURE AII-9, B). |
5. | Retract the syringe plunger to create negative pressure so that when the subclavian vein is entered, a flash is seen in the syringe. |
6. | Once this occurs, insert the wire through the trocar ( FIGURE AII-9, C), taking care to use the thumb to prevent any air intake into the trocar during transfers. |
7. | At no time should the operator let go of the wire while it is in the patient ( FIGURE AII-9, D). |
8. | Insert the wire at least 20 cm. |
9. | Remove the insertion trocar and incise the skin with an 11 blade to allow the dilator to pass easily ( FIGURE AII-9, E). |
10. | Pass the catheter and dilator over the wire ( FIGURE AII-9, F). |
11. | As soon as the wire is visible at the distal end of the catheter, release one hand from the wire proximally and grasp the wire at the distal end. |
12. | Fully insert the catheter before withdrawing the wire ( FIGURE AII-9, G). |
13. | Then remove the dilator and test the catheter before securing it to the patient’s skin with suture ( FIGURE AII-9, H). |
14. | Proper venous flow through the catheter suggests proper placement of the catheter. |
15. | Connect the catheter hub to an IV set ( FIGURE AII-9, I) and obtain a chest x-ray to confirm placement and ensure that a pneumothorax has not occurred due to catheter insertion. |
INDICATIONS
∙ | Central venous access for fluid resuscitation, hyperalimentation, or delivery of medications in intensive-care situations |
∙ | Delivery of medications that may cause sclerosis of smaller veins or necrosis of tissue if leaked from a peripheral vein |
∙ | Vascular access for plasmapheresis, dialysis, pacemakers, or Swan-Ganz catheter placement |
∙ | Vascular access for pulmonary or cardiac catheterization |
CONTRAINDICATIONS
∙ | Chest injury where a pneumothorax on the side of the line placement would compromise patient’s survival |
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Chest wall deformity or defect, congenital or acquired |
∙ | Infection or burn of the chest wall where the line would be placed |
CPT CODES
• | 36010 Introduction of catheter, superior or inferior vena cava |
• | 36011 Selective catheter placement, venous system, first-order branch, e.g., jugular vein |
ICD-9 CODES
• | 276.5 Dehydration |
• | 785.5 Shock, unspecified |
• | 785.59 Shock (hypovolemic, septic) |
C. THORACENTESIS
| Key Steps |
1. | Determine level of effusion. |
2. | Inject local anesthesia at insertion site. |
3. | Insert trocar and catheter. |
4. | Remove catheter. |
INSTRUCTIONS
1. | Prior to performing a thoracentesis, the operator must determine the level of pleural fluid with the patient sitting in the upright position ( FIGURE AII-10, A). |
2. | This can be done with percussion of the chest, egophony, or imaging studies. |
3. | Select an entry site just superior to a rib, along the posterior midclavicular line. |
4. | Clean the skin with an antiseptic solution and place a sterile drape over the area. |
5. | Draw up local anesthetic into a syringe using a 23-gauge, 1.5-inch needle to inject the anesthetic. |
6. | After creating a superficial wheal, pass the needle deep into the intercostal muscle, where 1 ml is injected. |
7. | Advance the needle 1 cm at a time, injecting 1 ml of anesthetic each time to anesthetize the deep layers superficial to the pleura. |
8. | Apply negative pressure to the syringe while advancing it. |
9. | A palpable “pop” can be felt when penetrating the tough, fibrous pleura. |
10. | Inject 2 ml of anesthetic into the pleural space and then withdraw the needle only slightly to infuse 1 ml more of anesthetic at the pleura. |
11. | This technique provides superb anesthesia. |
12. | Carefully insert the trocar just above the rib where the anesthesia has been placed. |
13. | Apply negative pressure to the syringe so that it is obvious when the pleural space is entered ( FIGURE AII-10, B). |
14. | Advance the catheter and then withdraw the trocar, leaving the catheter in the pleural space to collect fluid. |
15. | The catheter is never withdrawn through the trocar as long as either device is in the patient. |
16. | Using a large syringe, withdraw 30 to 60 ml of fluid to send for pathologic studies. |
17. | If a large effusion is present, then perform a therapeutic thoracentesis during which as much as several liters of fluid can be removed in one setting ( FIGURE AII-10, C). |
18. | After removing the desired amount of fluid, carefully and quickly withdraw the catheter to avoid an air leak into the chest cavity. |
19. | Cover the wound with a simple bandage and obtain a postthoracentesis x-ray. |
INDICATIONS
∙ | Diagnostic collection of pleural fluid |
∙ | Therapeutic extraction of pleural fluid affecting respiratory status |
∙ | Relief of spontaneous pneumothorax, though larger-caliber chest tubes are optimal |
CONTRAINDICATIONS
∙ | Coagulation defect (either medication related, congenital, or acquired), relative |
∙ | Suspicion that the lung is adherent to pleura |
∙ | Loculated fluid collection in the chest, in which case ultrasound guidance is recommended |
CPT CODES
• | 32000 Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent |
ICD-9 CODES
• | 511.9 Pleural effusion |
• | 511.1 Bacterial effusion |
• | 512.8 Pneumothorax |
D. ABDOMINAL PARACENTESIS
| Key Steps |
1. | Cleanse skin site. |
2. | Inject local anesthesia at entry point. |
3. | Insert IV or fenestrated catheter. |
4. | Remove device. |
INSTRUCTIONS
1. | Place the patient in a supine position rolled toward the left and cleanse the site with antiseptic solution. |
2. | Select the insertion site on or near the midclavicular line ( FIGURE AII-11, A). |
3. | Cover the area with a sterile protective drape. |
4. | Place a local anesthetic block. |
5. | First, place a wheal in the skin, then advance the needle into the subcutaneous layer and inject 1 ml of solution ( FIGURE AII-11, B). |
6. | Advance the needle into the muscle and inject the anesthetic into that layer as well. |
7. | Finally, as the needle is slowly advanced through the peritoneum, maintain suction on the syringe until entering the abdominal cavity ( FIGURE AII-11, C). |
8. | Once ascitic fluid is obtained, withdraw the needle slowly as 1 to 2 ml of lidocaine is injected to numb the peritoneal layer ( FIGURE AII-11, D). |
9. | There are two options for draining fluid. |
10. | For diagnostic paracentesis when removing small volumes, use an IV catheter to obtain a fluid sample. |
11. | Advance the catheter while applying suction by a syringe until the cavity is entered and fluid enters the syringe. |
12. | For therapeutic paracentesis, pass a larger catheter through a trocar into the peritoneal cavity. |
13. | Advance the trocar through the anesthetic area into the peritoneal cavity. |
14. | Then advance the catheter into the peritoneal cavity through the trocar. |
15. | Several liters of fluid can be drained from the abdomen using vacuum bottles attached to the catheter system. |
16. | Attach a stopcock system to the catheter. |
17. | This allows for control of the suction as desired during collection of the fluid. |
18. | The fluid will flow until the majority of the fluid is removed. |
19. | At the conclusion of the procedure, remove the needle and catheter. |
20. | Apply a dressing over the wound in case there is any further fluid leak. |
INDICATIONS
∙ | Intraabdominal ascites |
∙ | Suspected bacterial peritonitis |
∙ | Need for tube delivered nutrition, dye, or medications |
CONTRAINDICATIONS
∙ | Coagulation defect (either medication related, congenital, or acquired) |
∙ | Second-trimester or third-trimester pregnancy |
∙ | Previous abdominal surgeries (multiple, in which adhesions are more likely) |
∙ | Local infection at the site of paracentesis |
∙ | Acute abdomen, acute distension (not ascites), or bowel obstruction |
CPT CODES
• | 49080 Abdominal paracentesis or peritoneal lavage, initial |
• | 49081 Abdominal paracentesis or peritoneal lavage, subsequent |
ICD-9 CODES
• | 789.5 Ascites |
• | 197.6 Ascites, malignant |
• | 567.2 Subacute bacterial peritonitis |
• | 014.0 Ascites, tuberculous |
12. OBSTETRICSA. VAGINAL DELIVERY
| Key Steps |
1. | Complete the second stage. |
2. | Controlled delivery of the head. |
3. | Delivery of the shoulders. |
4. | Delivery of the placenta. |
INSTRUCTIONSFirst Stage of Delivery
1. | During the ending of the first stage of delivery, the fetal head engages the maternal pelvis and rotates from a transverse lie to a coronal lie. |
2. | Normally, the head aligns with the fetal occiput anterior, though occiput posterior may occur approximately 20% of the time. |
3. | Once the rotation is complete, it allows for easier descent through the pelvic floor through the vagina. |
4. | Once the patient is fully dilated to 10 cm, she often has a strong urge to push with contractions. |
5. | Ideally, three or four pushes are done with each contraction, each push lasting 8 to 10 seconds. |
6. | The propulsive effort of both the uterine contraction and the Valsalva pressure supplied by the abdominal muscles and diaphragm moves the infant’s head farther down the vaginal canal. |
Second Stage of Delivery
1. | The normal second stage of labor is approximately 1 hour for most multiparous patients and up to 2 hours for primiparous patients. |
2. | As the fetus moves farther down to +3 to +4 station, the infant’s head becomes visible as the labia separate with each push ( FIGURE AII-12, A). |
3. | If tolerated by the infant, allowing the perineum to stretch reduces the degree of tearing as the head is delivered. |
4. | When the head is crowning, slight counterpressure to the head applied during the delivery process can prevent a rapid expulsion of the head as it passes through the final resistance of the vulva ( FIGURE AII-12, B). |
5. | Once the head is delivered, the operator tracks a finger along the neck to check for a nuchal cord ( FIGURE AII-12, C). If a cord is present, reduce it before the shoulders are delivered. Reduction can be accomplished by slipping the cord over the head in most instances. |
6. | Apply traction to head and neck in a downward and forward direction to deliver the anterior shoulder. Minimal lateral extension of the neck reduces the risk of traction injury to the brachial plexus ( FIGURE AII-12, D). |
7. | Immediately after the delivery of the anterior shoulder, raise the head to allow the posterior shoulder to deliver over the posterior fourchette. |
8. | Place the infant on the operator’s lap, suction the airway, and cut the cord ( FIGURE AII-12, E and F). |
9. | Place the stable newborn immediately on the mother to allow for early contact between mother and infant. |
Third Stage of Delivery
1. | After the infant is delivered, the third stage of labor begins. |
2. | Cross-clamp the cord with a hemostat to allow gentle traction to be applied to the cord, encouraging the progressive delivery of the placenta. |
3. | Administer oxytocin at this time to encourage placental delivery. Oxytocin administration in the third stage of labor reduces the risk of maternal hemorrhage at no increased risk of retained placenta. |
4. | The placenta delivers spontaneously after approximately 10 minutes and is inspected to ensure that there are no missing pieces that may suggest that a remnant of a cotyledon remains in the uterus ( FIGURE AII-12, G). |
5. | Massage the uterus to encourage contraction and hemostasis. |
6. | After the patient’s bleeding has slowed, inspect the perineum, vaginal orifice, and cervix for lacerations, which may require specific repair to avoid further bleeding and retain appropriate anatomy. |
INDICATIONS
∙ | Patient in active labor |
∙ | Fetus in no distress |
CONTRAINDICATIONS
∙ | Vasa previa or placenta previa |
∙ | Abnormal fetal lie |
∙ | Cord prolapse |
∙ | Prior classical cesarean section |
∙ | Active genital herpes infection |
∙ | Fetal deformities |
CPT AND ICD-9 CODES
• | Vaginal delivery |
• | CPT and ICD codes depend on many variables of prenatal and postnatal care. Please refer to manuals for appropriate codes. |
B. EPISIOTOMY-LACERATION REPAIR
| Key Steps |
1. | Inject anesthesia. |
2. | Place an anchor stitch and mucosal closure. |
3. | Perform deep layer closure. |
4. | Perform perineal subcuticular closure. |
5. | Place a final anchor stitch. |
INSTRUCTIONS
1. | To repair a midline laceration or episiotomy, first inspect the area to determine the extent of the laceration. |
2. | Identify the vaginal apex, posterior fourchette, and perineal apex. |
3. | It is critical that the two sides of the posterior fourchette are approximated during the repair. |
4. | Inject local anesthesia along the edges of the laceration to provide a block for the repair. |
5. | If an epidural is in place with a good block, local anesthesia is not required. |
6. | The choice of suture varies by operator, but 3-0 chromic, Dexon, or Vicryl absorbable is often selected for closure. |
7. | Place an anchoring stitch on the inner, or vaginal, aspect of the laceration just above the apex of the tear or episiotomy. |
8. | Use a continuous running suture to close the internal vaginal portion of the tear to the posterior fourchette. |
9. | Once near the posterior fourchette, direct the suture deep to begin a deep layer closure of the perineal aspect of the laceration. |
10. | Run the suture posteriorly in the subcutaneous and deep layers down to the posterior aspect of the tear. |
11. | Once at the posterior aspect, perform a subcuticular repair in the posterior to anterior direction along the perineal body. |
12. | Run the suture continuously to the posterior fourchette until the skin is fully closed. |
13. | Once the external skin is closed, bring the suture up into the vaginal mucosa and anchor it with another stitch along the posterior vaginal wall to bury the knot. |
14. | After the repair is completed, perform a digital rectal exam to test the integrity of the repair and to ensure that no sutures were placed through the rectal mucosa. |
15. | In instances in which there is significant tearing toward the anus, perform the rectal examination prior to the repair to ensure adequate layer-by-layer closure. |
16. | Clean the patient and reevaluate the amount of lochia to ensure that bleeding is well controlled. |
17. | Control the pain and swelling of the perineum with oral analgesics and ice packs as needed. |
INDICATIONS
∙ | Instrumented delivery |
∙ | Shoulder dystocia |
∙ | Perineal barrier to effective delivery |
∙ | Fetal prematurity |
∙ | Breech presentation |
CONTRAINDICATIONS
∙ | Extensive vulvar varices |
CPT CODES
• | 59300 Episiotomy or laceration repair by other than attending |
ICD-9 CODES
• | 664.04 First-degree perineal laceration |
• | 664.14 Second-degree perineal laceration |
13. REPRODUCTIVE—FEMALEA. INTRAUTERINE DEVICE (IUD) INSERTION
| Key Steps |
1. | Determine uterine position. |
2. | Clean cervix with antiseptic solution. |
3. | Visualize cervix, stabilize with tenaculum if needed. |
4. | Sound uterus. |
5. | Mark IUD catheter and insert IUD. |
6. | Remove catheter, cut strings. |
INSTRUCTIONS
1. | Before inserting an IUD, the physician must know the position and size of the uterus, which can be determined with a bimanual examination. |
2. | In most instances, a preprocedure pregnancy test should be performed, and its outcome should be negative. |
3. | Insert the speculum and clearly visualize the cervix. |
4. | Clean the cervix with antiseptic solution. |
5. | Insert the sound and apply pressure to the internal os until it relaxes. |
6. | A palpable give will be felt when the internal os dilates. |
7. | It may be necessary to stabilize the uterus with the application of the tenaculum to the cervix. |
8. | Before being inserted, the IUD must be prepared in a sterile manner. |
9. | Arm the Paraguard device in a sterile manner within the inner packaging. |
10. | Retract the Mirena device into the insertion catheter and lock it into position, using the strings at the base of the handle. |
11. | Set the marker ring on the IUD insertion catheter to match the sound results for both devices. |
12. | Insert the IUD until the ring is flush to the cervix with the Paraguard device. |
13. | With the marker ring applied to the cervix, hold the center plunger still while withdrawing the insertion tube out of the cervix. |
14. | When inserting a Mirena IUD, leave the marker ring 1 cm short of the cervix before releasing the device in the uterus. |
15. | Pull back the release lever within the handle 1 cm and then advance the catheter up into the uterus so that the marker ring is flush with the cervix. |
16. | Finally, fully retract the release lever in the handle to free the IUD from the catheter. |
17. | Withdraw the catheter and see the strings protruding from the os. |
18. | Trim the strings down to 2 to 3 cm in length. |
INDICATIONS
∙ | Patient desires reversible, longer-term contraception |
∙ | Treatment of dysfunctional uterine bleeding and cramps with progestin-containing IUD |
∙ | Emergency contraception if insertion is performed soon after unprotected intercourse (5 days) |
CONTRAINDICATIONS
∙ | Active pelvic inflammatory disease (PID) |
∙ | Active cervical infection |
∙ | Nonreducible cervical stenosis, preventing insertion |
∙ | Poorly defined uterine position and anatomy as determined by pelvic examination |
∙ | Allergy to copper for copper-containing IUD |
RELATIVE CONTRAINDICATIONS
∙ | Multiple sexual partners, placing patient at risk for PID |
∙ | Nulligravida status |
CPT CODES
• | 58300 Insertion of IUD (not including device) |
ICD-9 CODES
• | V25.1 Contraceptive management: IUD |
B. IUD REMOVAL
| Key Steps |
1. | Visualize cervix, identify IUD strings. |
2. | Grasp strings with ring forceps. |
3. | Extract IUD. |
INSTRUCTIONS
1. | Place the patient in the lithotomy position and insert a speculum to visualize the cervix. |
2. | Identify the IUD strings. |
3. | Remove the IUD by firmly grasping the IUD string in the vault, using a ring forceps. |
4. | With smooth, gentle traction, pull the IUD out of the uterus. |
INDICATIONS
∙ | Expired IUD (1 to 5 years for progesterone IUD, 10 years for copper IUD) |
∙ | Request for removal |
∙ | Overall medical condition that warrants removal |
∙ | Pregnancy |
∙ | Pelvic inflammatory disease |
∙ | Lower genital malignancy |
∙ | Dyspareunia |
∙ | Uterine perforation |
∙ | Partial expulsion |
∙ | Some precancerous lesions of cervix or endocervical canal to allow for treatment |
∙ | High risk for sexually transmitted diseases |
∙ | Menopause |
∙ | Desire to become pregnant |
∙ | Side effects causing significant patient discomfort |
∙ | Any condition that makes a woman ineligible for IUD use |
CONTRAINDICATIONS
CPT CODES
ICD-9 CODES
• | V25.1 Contraceptive management: IUD |
• | V25.42 IUD removal |
• | 996.76 IUD causing menorrhagia |
C. DIAPHRAGM INSERTION
| Key Steps |
1. | Place patient in lithotomy position. |
2. | Measure vaginal vault. |
3. | Determine size of diaphragm. |
4. | Gently insert and palpate diaphragm-covered cervix. |
INSTRUCTIONS
1. | Place the patient in the lithotomy position. |
2. | With index finger, gently determine the distance from the posterior fornix to the inside of the symphysis pubis, which will be the size of the diaphragm. Most women require a 70-mm to 80-mm size. |
3. | Apply lubricating jelly to the dome and entire rim of the diaphragm. The patient must understand that effectiveness requires use of spermicidal jelly, not lubricant. |
4. | With the diaphragm folded in half in one hand and the vulva separated with the other, gently insert the diaphragm into the vagina in the direction of the posterior fornix and gently place the anterior edge under the pubis. |
5. | Determine correct placement by feeling that the cervix is fully covered by the diaphragm. |
6. | The diaphragm should be comfortable to the patient. |
7. | Remove the diaphragm by hooking the anterior rim with the index finger and pulling it out through the introitus. |
8. | Teach the patient to insert, check position of, and remove the diaphragm; provide written instructions. |
INDICATIONS
∙ | Desire for self-administered reversible contraception of moderate effectiveness |
CONTRAINDICATIONS
∙ | When pregnancy must be prevented owing to maternal medical condition, use more effective method |
∙ | Inability to tolerate or understand application of self-insertion diaphragm device |
∙ | Not to be used for reliable prevention of sexually transmitted diseases |
CPT CODES
• | 57170 Diaphragm or cervical cap fitting with instructions |
ICD-9 CODES
• | V2509 Family planning advice |
• | V2502 Initiation of other contraceptive measures |
14. URINARYA. BLADDER CATHETERIZATION—FEMALE
| Key Steps |
1. | Position patient. |
2. | Prepare catheter, check balloon. |
3. | Cleanse labia and urethral meatus. |
4. | Insert catheter completely into bladder. |
5. | Inflate catheter balloon. |
INSTRUCTIONS
1. | Place the patient in the lithotomy position ( FIGURE AII-13, A). |
2. | After donning sterile gloves and draping the patient’s genitals, prepare the catheter for insertion. |
3. | Thoroughly cleanse the labia and the urethral meatus with antiseptic solution ( FIGURE AII-13, B). |
4. | Lubricate the catheter with 2% lidocaine jelly ( FIGURE AII-13, C) and gently insert it through the urethra ( FIGURE AII-13, D). |
5. | Pass at least 20 cm of the catheter into the urethra to ensure that it is fully within the bladder ( FIGURE AII-13, E). |
6. | Once urine is obtained, if the catheter is to be left inside, inflate the balloon with 10 ml of sterile water and gently pull the catheter outward to ensure that the balloon is maintaining the catheter in position ( FIGURE AII-13, F). |
7. | Set up the closed urine collection system and secure the catheter to the patient’s thigh with tape. |
INDICATIONS
∙ | Relief of urinary obstruction |
∙ | Monitoring of urine output |
∙ | Obtaining a sterile urine specimen |
∙ | Instillation of medications or dyes into the bladder |
∙ | Incontinence management |
∙ | Measurement of post-void residual volumes |
CONTRAINDICATIONS
∙ | Suspected pubic symphysis fracture (blood at the urethral meatus in trauma patient) |
∙ | Known fixed obstruction of the urethra (stricture or malignant fixation of urethra) |
∙ | Acute infection of prostate or urethra likely |
CPT CODES
• | 53670 Simple catheterization |
ICD-9 CODES
• | 598.9 Urethral stricture (nontraumatic) |
• | 598.1 Urethral stricture (traumatic) |
• | 596.0 Bladder neck obstruction (acquired) |
• | 788.20 Urinary retention |
• | 788.30 Urinary incontinence |
B. BLADDER CATHETERIZATION—MALE
| Key Steps |
1. | Position and drape patient. |
2. | Prepare and lubricate catheter. |
3. | Cleanse urethra. |
4. | Advance catheter into bladder. |
5. | Obtain specimen, remove catheter. |
INSTRUCTIONS
1. | Place the patient in the supine position. |
2. | Don sterile gloves and drape the patient’s genitals. |
3. | Lubricate the catheter with 2% lidocaine jelly. |
4. | Thoroughly cleanse the urethral meatus with antiseptic solution ( FIGURE AII-14, A) and lubricate the urethra ( FIGURE AII-14, B). |
5. | Gently insert the catheter through the urethra ( FIGURE AII-14, C). |
6. | Pass the entire length of the catheter into the urethra up to the junction of the catheter and the inflation port ( FIGURE AII-14, D). |
7. | Once urine is obtained, if the catheter is to be left inside, inflate the balloon with 10 ml of sterile water and gently pull the catheter outward to ensure that the balloon is maintaining the catheter in position ( FIGURE AII-14, E). |
INDICATIONS
∙ | Relief of urinary obstruction |
∙ | Monitoring of urine output |
∙ | Obtaining a sterile urine specimen |
∙ | Instillation of medications or dyes into the bladder |
∙ | Incontinence management |
∙ | Measurement of post-void residual volumes |
CONTRAINDICATIONS
∙ | Suspected pubic symphysis fracture (blood at the urethral meatus in trauma patient) |
∙ | Known fixed obstruction of the urethra (stricture or malignant fixation of urethra) |
∙ | Acute infection of prostate or urethra likely |
CPT CODES
• | 53670 Simple catheterization |
ICD-9 CODES
• | 600.0 Prostatism |
• | 598.9 Urethral stricture (nontraumatic) |
• | 598.1 Urethral stricture (traumatic) |
• | 596.0 Bladder neck obstruction (acquired) |
• | 788.20 Urinary retention |
• | 788.30 Urinary incontinence |
© 2011
Elsevier Inc. Tous droits réservés.
