​Clinical Procedures - Coronary Angiography/Angioplasty
Indications
• Diagnostic: unstable or refractory angina, acute coronary syndrome, positive or inconclusive stress testing
• Emergency therapeutic: where possible, patients presenting with acute ST-elevation myocardial infarction should have primary coronary intervention rather than thrombolysis
• Elective therapeutic: suitable 'target lesion' identified on diagnostic coronary angiogram.
Contraindications
• Absolute: refusal of patient consent
• Relative: acute renal failure, pulmonary edema, known radiographic contrast allergy, uncontrolled hypertension, active gastrointestinal haemorrhage, acute stroke, and untreated coagulopathy.
Procedure
• Percutaneous access via a guide needle into a peripheral artery (most commonly the radial artery)
• Guide catheter is introduced, the tip is placed at the coronary ostium, radio-opaque contrast is injected, and real-time x-ray is used to visualize the blood flow through the coronary
• The coronary guidewire is inserted through the catheter into the coronary artery using x-ray guidance
• The guidewire tip is passed across the site of stenosis
• The balloon catheter is passed over the guidewire until the deflated balloon lies across the target lesion
• The balloon is then inflated and compresses the plaque and stretches the artery wall. A stent (wire mesh tube) can be inserted using a similar technique and be left in place maintaining the arterial lumen
• The guidewire, catheter, and sheath are carefully removed
• The patient should remain supine for 4 hours following the procedure unless an arterial closure device has been used.
Risks
• Minor: contrast allergy, vasovagal reaction, hemorrhage and hematoma at puncture site, thrombosis formation, false aneurysm, AV fistulation, pulmonary edema, and renal failure due to contrast nephropathy
• Major: limb ischaemia, coronary artery dissection, aortic dissection, ventricular perforation, air or atheroma embolism, ventricular arrhythmias failure of procedure, and need to proceed to coronary artery bypass graft
• Death (<1 in 1000).

Patient Preparation
• Pre-procedure check list: written consent, group and save, ECG, check full blood count/clotting/U&Es.
Other Information for Junior Doctors
• Coronary angioplasty is associated with increased thrombus formation (balloon inflation disrupts the intima, revealing prothrombotic cores of plaques), therefore antiplatelet therapy is necessary
• Patients will need to have long-term antiplatelet therapy; usually lifelong aspirin 75mg once daily, but they will also need clopidogrel 75mg once daily (see local guidelines: usually 3 months for bare metal stents and 12 months for drug-eluting stents or angioplasty after acute coronary syndrome)
• Patients with renal failure should be carefully considered. lodinated contrast can be nephrotoxic and renal decompensation may occur following coronary angiography/plasty. The risk can be minimized by hydration before and after the procedure. Renal function should be carefully monitored. Check local guidelines.

​Clinical Procedures - Echocardiography
Indications
• Myocardial infarction: assess wall motion and left ventricular function
• Valvular heart disease: assess competency and examine prostheses
• Embolic stroke: to exclude a cardiac embolic source
• Infective endocarditis: look for valvular vegetations
• Cardiomyopathy: assess ventricular dilatation/hypertrophy and function
• Congenital heart disease
• Pericardial disease
• Pericardial effusion: distribution of fluid and suitability for drainage
• Aortic disease: severity and site of aneurysm, dissection, or coarctation.
Contraindications
• The only contraindication is lack of patient consent or if the patient is unable to cooperate.
Technology
• Echocardiography is an ultrasound examination and uses the same technology (and machines) as general ultrasound. See separate topic
• Ultrasound becomes increasingly less diagnostic at greater depths and cannot see through lung. Images in large individuals are often suboptimal and the heart may not be seen at all in patients with hyperinflated lungs.
Procedure
• Time taken will vary depending on examinations performed and complexity of the findings. Most examinations last between 20-25 minutes
• With the patient lying on their left side, the operator uses a hand-held probe coated with gel to examine the heart usually via the anterior chest and epigastrium.
Risks
•There is no published evidence that ultrasound has ever directly caused any harm to a patient
• Heating: some equipment can produce temperature rises of 4°C in bone. Most equipment in clinical use is unlikely to increase tissue temperature more than the 1.5°C which is considered 'safe
• Non-thermal hazard: ultrasound has been demonstrated to produce tiny gas pockets and bubbles in animal models but there is no evidence that diagnostic ultrasound can cause harm to tissues other than neonatal lung.

Patient Preparation
• No preparation is required.
Other Information: Type of Echocardiography
Along with 2-dimensional transthoracic echocardiography, the following methods exist:
• 3D: uses computer software to produce a 3-dimensional image. Useful in left-ventricular functional assessment especially post-infarction
• 4D: 3D imaging with real-time movement captured
• TOE: transoesophageal echo is an invasive procedure. It requires written consent and is performed under sedation with local anaesthetic spray to the upper pharynx. The probe is covered, lubricated, and passed into the esophagus behind the heart. It is used to visualize the posterior cardiac structures. The investigation of choice for infective endocarditis
• Stress echo: used to assess myocardial ischaemia at 'rest and during
'stress'. Stress is induced by exercise or (more commonly) by an IV infusion of dobutamine in a controlled environment
• Bubble studies: used to assess for intracardiac shunts such as atrial or ventricular septal defects or patent foramen ovale. Air bubbles are agitated in a syringe and injected into a peripheral vein. The Valsalva manoeuvre is performed and, if a shunt exists, bubbles will be seen moving from the right side of the heart to the left.

​Clinical Procedures - Exercise Tolerance Testing (ETT)
Indications
• Assessment of chest pain in those with known coronary artery disease (there is no longer a role for ETT in patients presenting with chest pain who do not have a history of coronary artery disease)
• Assessment of haemodynamic response in those with known valvular disease who are asymptomatic
• Diagnosis of exertionally induced arrhythmias or syncope.
Contraindications
• Any undiagnosed or previously unknown murmur (patient should undergo echocardiogram first)
• Severe aortic stenosis (risk of syncope)
• Hypertrophic cardiomyopathy with significant outflow obstruction (risk of syncope)
• Severe hyper- or hypotension
• Unstable angina (should undergo coronary angiography)
• Known severe left main stem disease
• Untreated congestive cardiac failure
• Complete heart block
• Aortic aneurysm
• Acute myocarditis or pericarditis
• Any recent pyrexial or 'flu-like' illness.
Procedure
• ECG electrodes are put on the patient's chest and a sphygmomanometer cuff on an arm
• The patient is asked to walk on a treadmill connected to the computer whilst their ECG, blood pressure, and heart rate are monitored. The speed and incline of the treadmill increase according to set protocols:
• Bruce protocol: for assessment of physically fit and stable patients with suspected coronary artery disease, 7 stages starting at a 10% gradient at 1.7mph and increasing to 22% gradient and 6mph
• Modified Bruce protocol: used in elderly patients or those who have been stabilized after a suspected episode of unstable angina.
Starts at 1.7mph and 0% gradient and increases the gradient slowly to 10%
• Termination of the test depends on the results seen (see box).
Risks
• Risks are those associated with exercise and include:
• Arrhythmia, cardiac ischaemia, myocardial infarction, syncope.

Patient Preparation
• No specific preparation is required. Patients are asked not to eat or drink for 3 hours prior to the test
• Comfortable clothing and shoes should be worn.
Indications for termination of procedure
• Patient requests to stop
• Symptoms: fatigue, angina, dizziness, significant breathlessness
• Signs: drop in oxygen saturations <94%, target heart rate achieved, hypotension during exercise (e.g. BP <100mmg), significant hypertension (e.g. BP >200mmHg)
• ECG: any atrial or ventricular arrhythmia, frequent ventricular ectopics, new AV or bundle branch block, ST segment shift >1mm.
Causes of false positive results or low specificity
• Often due to difficulty interpreting results as result of resting ST segment abnormalities:
•Wolf-Parkinson-White syndrome, left bundle branch block, atrial fibrillation, left ventricular hypertrophy, digoxin therapy, hyperventilation, biochemical electrolyte abnormalities (e.g. hypo- or hyperkalaemia), cardiomyopathies, left ventricular outflow obstruction
Beta-blocker therapy prevents the appropriate heart rate/blood
pressure response during testing.

​Clinical Procedures - Transferring a Patient Using a Hoist
Limited input from patient. Use this technique to transfer patients who are unable to weight bear, sit up in the bed, or use a bedpan.
Equipment
• Hoist
• Sling: single-patient use (disposable).
Procedure
• D There should be at least 2 handlers. Agree who will give commands:
• Check care plan regarding patient's suitability for hoist usage
• Before getting equipment, ensure manoeuvre is explained to patient
• Select appropriate sling: small, medium, or large
• Ensure hoist and sling are compatible
• Check hoist is able to take patient's weight: most are able to take up to 25 stones (170kg)
• Ensure issues around patient's privacy and dignity are appropriately addressed
• Check bed is at waist height to prevent staff injuries
• Staff stand either side of bed facing each other
• © Check brakes on bed secure
• Patient should be rolled to one side of bed:
•Encourage patient to do so without staff assistance if capable
• Lay the hoist sling on the bed
• Roll the patient to other side of the bed:
• Sling should now be in a position from patient's head to thigh
• Place the loops at shoulder end of sling on arm of hoist
• Pass the thigh-end loops through each other, then place on arm of hoist:
• D Ensure the loops are correctly positioned before moving
. 1 handler should now manage the controls of the hoist.
• Second handler lowers patient's bed, then moves behind the patient/hoist, ready to guide them into the chair
• Move patient back with hoist
• Second handler gently guides patient into the chair whilst they are
lowered
• Once patient is in chair, disconnect loops from hoist
• Remove sling from beneath lower legs of patient.
Procedures Tips
• Ensure sufficient time available to safely complete the manoeuvre
• Check bed area for any furniture/equipment that could be moved (e.g.
trailing wires)
• Always check items such as IV fluids, catheters, and drains are safe and unlikely to be caught in hoist or pulled out during procedure
• Check with qualified staff/physiotherapists regarding any changes in the patient's condition prior to manoeuvre. Transfer may be inadvisable
• Staff should wear suitable (preferably low-heel) footwear and non-restrictive clothing
• Hoist should only be used to transfer patients short distances (bed-side manoeuvres only)
• Ensure hoist is fully charged before commencing manoeuvre
• Ensure the brakes of the hoist are off. This will allow the hoist to find its own centre of gravity.
Risks
• Potential injuries to patient or staff arising from trailing leads, drains, etc.
• Disconnection of equipment during manoeuvre:
• Watch out for IV pumps, syringe drivers, catheters.
Documentation
• All patients should have assessments carried out within 24 hours of admission
• Care plan should be maintained/consulted as appropriate
• If there are any issues with equipment or manoeuvre, advise nurse in charge, document in notes, and complete an appropriate incident form

​Clinical Procedures - Transferring a Patient Laterally Using a Transfer Board 
No input from patient. Use this technique to transfer patients who are unable to move themselves.
Equipment
• Patient transfer board or 'Patslide®
Procedure
• There should be at least 3 handlers. Agree who will give commands
• Open transfer board (if folded) and place on bed/trolley you plan to transfer patient to
• Explain the manoeuvre to the patient
• Place destination bed/trolley alongside origin bed/trolley:
• Ensure there is only a minimal gap between the beds/ trolley involved
• Check bed is at waist height to prevent staff injuries
• Staff stand either side of bed/trolley facing each other, 2 people on the 'destination' side and 1 on the other
• Check brakes on bed and trolley secure
• Staff at the patient's bedside to lean over patient and grip bed sheet as close to the patient's body as possible with both hands and roll the patient towards them
• Staff at the bed/trolley onto which patient is to be transferred, put transfer board onto patient's bed/trolley
• Staff at bed-side allow patient to roll back onto board (which should be under the bed sheet)
• On command of 'Ready, Steady, Move'
• Handlers push and pull patient gently across on transfer board, dependent upon their position:
• Staff should ensure their arms remain straight and they do not lean forward, bending at the waist
• Once patient is transferred, ensure sheets and blankets are comfortably in place
• Bed rails should be put into place as appropriate

Procedure Tips
• Do not rush. Ensure sufficient time is available to safely complete the
manoeuvre
• Ensure the patient and handlers are fully informed regarding steps of the manoeuvre
• Check bed area for any furniture/equipment that could be moved
• Always check IV fluids, catheters, drains, etc. are safe and unlikely to be caught or pulled out during procedure
• Move any attachments onto transferring bed/trolley prior to the move
• Check with qualified staff/physiotherapists regarding any changes in the patient's condition prior to manoeuvre
• Staff should wear suitable (preferably low-heel) footwear and non-restrictive clothing
• Check with ward staff that patient can be laid flat
• If nasogastrically-fed, ensure it is switched off to prevent patient aspirating
• Do not climb onto the bed/trolley. There is a high risk of injury to the handler
 Ensure both surfaces are the same height, making the manoeuvre
both easier and more comfortable for the patient.
Risks
• Potential injuries to patient/staff arising from trailing leads and drains
• Disconnection of equipment during manoeuvre
• If the gap between the beds/trolley is too wide, patient may fall through!
Documentation
• All patients should have assessments carried out within 24 hours of admission. Care plan to be maintained/consulted as appropriate
• Any issues or problems with equipment or manoeuvre should be conveyed to the nurse in charge, documented in the notes, and an appropriate incident form completed.

Clinical Procedures - Assisting a Patient to Change Position in Bed (Glide Sheet) 
Equipment
• Single-patient use, multi-directional slide sheet/glide sheet:
• May be heavy-duty plastic or fabric
• Half size: fits under average-sized patient from shoulder to knee
• Full size: head to toe
• Minimum of 2 staff.
Procedure
• Ensure patient is aware of the procedure, understands, and has given consent, if able
• Patient should be lying flat in bed
• D Check patient is suitably clothed/covered
• Discuss desired end position of patient with the other handlers)
• Move the bed to waist height to prevent staff injuries:
• Staff should not have to overstretch to complete the manoeuvre
• Ensure the brakes on bed are secure
• Staff should stand either side of the bed facing each other
• Staff should ensure they are wearing appropriate low-heeled, properly fitting footwear, and that laces are not trailing
• To place glide sheet under patient, roll patient on bed sheet over to one side of the bed. Either:
• 1 staff member leans over patient and pulls the bottom sheet to roll patient onto one side
• If possible, encourage the patient to roll themselves onto one side.
• The handler nearest the patient should hold sheet (and patient on their side) whilst the glide sheet is inserted by the other handler
• Place the glide sheet between mattress and bottom sheet
• The second handler should hold the glide sheet and push as far as possible under bottom sheet and the patient rolls back onto their back

• Repeat manoeuvre from the other side until glide sheet is fully under the patient
• Once the sheet is in place, agree which handler will give command to move patient
• Both handlers should grip the bed sheet, with both hands, as close to patient as possible
• Place both feet firmly on the floor
• On command of 'Ready, Steady, Move', both handlers grip bottom sheet and gently move patient to previously agreed position
• Place pillows appropriately for the patient's revised position
• Reverse patient movement procedure (onto his/her side)
to remove glide sheet.
Procedures Tips
• Do not rush. Ensure sufficient time is available to explain the manoeuvre to the patient and safely complete the manoeuvre
• Ensure the patient is informed regarding the manoeuvre
• Check bed area for any furniture/equipment that could be moved to allow more space to complete the manoeuvre
• Always check that IV fluids, catheters, drains, and other devices are safe and not likely to be pulled out during procedure
• Check with qualified staff any changes in the patient's condition prior to the manoeuvre
• Check with staff whether the patient has any history of cognitive problems, violence, or aggression or has any health problems which may prevent or impact upon the manoeuvre
•  If appropriate, ensure bed rails are put back into place following procedure to prevent patient falling from bed
Replace glide/slide sheet next to patient's bed-head, checking it is labelled for the named patient only
• Consult physiotherapists and/or ward staff if unsure of any of the above.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any issues or concerns should be documented in the patient's notes to ensure other ward staff are aware of problems.

​Clinical Procedures – Pericardiocentesis 
Equipment
• Echocardiogram machine and sterile probe cover
• Pericardial drain kit (14 gauge needle, syringe, guidewire, pigtail catheter and drain)
• Sterile drape and towels
• lodine solution
• Sterile gloves and gown
• Local anaesthetic (1% lidocaine)
• 2 x 10mL syringe
• Orange/blue/green needles
• Sterile gauze
• 50mL syringe
• 3-way tap
• Suture, scissors, sticky dressing (e.g. Tegaderm®).
You will also need:
• IV access
• ECG monitoring
• Access to 'crash' trolley (defibrillator and emergency drugs).
Procedure
• Introduce yourself, explain the procedure, and obtain informed written consent
• Ensure IV access, ECG monitoring, normal clotting, and access to resuscitation equipment
• (Consider light sedation)
• Position patient supine with 20-30° head tilt
• Ensure all equipment is sterile and laid out on sterile trolley
• Wash hands using surgical scrub technique and put on the sterile gown and gloves
• Clean and drape site at the inferior border of the sternum:
• The point of needle insertion is immediately below and to the left of the xiphisternum
• Confirm location of effusion using echocardiogram machine with sterile probe cover

• Infiltrate overlying skin and subcutaneous tissue with 1% lidocaine. (Always aspirate before each injection.)
• Attach the 10mL syringe attached to the 14G needle
• Insert the needle between the xiphisternum and left costal margin advancing slowly at 35° to the patient and aiming towards the patient's left shoulder. Aspirate continuously as the needle advances:
• Pericardial fluid is usually aspirated at about 6 8cm depth
Depending on the size of the pericardial effusion and indication for the procedure, you may wish to attach the 50mL syringe and aspirate fluid to send for diagnostic purposes
• A modified Seldinger technique should now be used to insert the pericardial drain
• Once pericardial fluid is aspirated, hold the needle in position, remove the syringe, and insert the guidewire slowly through the needle into the pericardial space
• Remove the needle, holding the wire in place at all times
• Pass the catheter over the wire into the pericardial space
• Once the catheter position is confirmed on echo, remove the wire and attach the 3-way tap and drain bag
• Suture the drain in place and dress to maintain sterility
• Request a CXR to exclude iatrogenic pneumothorax.
Documentation
• Date, time, and place
• Name and grade of person who performed the procedure (and anyone who supervised)
• Consent obtained (enclose copy of consent form)
• Aseptic technique used and volume of anesthetic used
• Approach taken and anatomy confirmed by echocardiogram
• Any difficulties, i.e. "first pass' or 'second attempt' etc.
• Appearance of pericardial fluid aspirated
• Volume of pericardial fluid aspirated.

Indications
• Treatment of cardiac tamponade
• Symptomatic pericardial effusion
• Diagnostic pericardiocentesis
• During CPR to exclude cardiac tamponade as a reversible cause of cardiac arrest.
Contraindications
• Cardiac tamponade secondary to cardiac trauma or aortic dissection (surgical intervention is preferable)
• Recurrent pericardial effusions (surgical pericardial window indicated).
Risks
• Pneumothorax
• Myocardial perforation
• Cardiac tamponade
• Coronary artery laceration
• Cardiac arrhythmias
• Intra-abdominal trauma (especially to liver)
• Haemorrhage
• Infection
• Acute pulmonary oedema
• Failure of procedure
• Death.
Procedure Tips
• Pericardiocentesis should be performed by a trained doctor (either cardiologist or thoracic surgeon usually) preferably in a sterile environment (theatre or the cardiac catheterization lab) and under echocardiographic guidance, with access to full resuscitation equipment
•  The only exception is during cardiopulmonary resuscitation when pericardiocentesis is performed as an emergency to exclude cardiac tamponade as a reversible cause of cardiac arrest
•  Always check the patient's clotting before commencing pericardiocentesis
• The clinician who performed the procedure should confirm the position of the drain using echo
• Always request a post-procedure chest radiograph to exclude iatrogenic pneumothorax.

​Clinical Procedures – Cleaning An Open Wound 
Indications
• Wounds presenting to the Emergency Department.
Contraindications
• Major injuries: vascular compromise, tendon rupture, nerve injury, open factures or joints. These require senior advice and possibly specialist referral.
Risks
• Infection, failure to decontaminate wound
• Haemorrhage, scar, further surgery.
Procedure Tips
• Instead of using a syringe, a normal saline bag and giving set can be used
• For finger lacerations, a digital nerve block provides good analgesia:
• Don't use adrenaline as this can infarct the digit!
• In an ATLS scenario, open wounds should be photographed and covered with an antiseptic-soaked dressing and bandage. The photograph will allow wound inspection by others, without the need to remove bandages and contaminate the wound further
• D Always x-ray glass and metal wounds
• Small superficial wounds with no evidence of contamination on inspection or from the history can be closed with interrupted non-absorbable sutures:
• Patients need to be given information on wound care, signs of infection, and when the sutures should be removed
• Superficial face and head wounds can be closed with skin glue
•In some centres, facial wounds are only sutured by maxillofacial specialists to improve cosmetic results. Check your local policy.
Documentation
• Time, date, mechanism of injury
• Vaccination status
• Sensation and pulses
• Analgesia
• Check for nerve, tendon, and vascular injuries
• Draw diagram of wound site and inspection findings
• How much wash was used?
• If sutured, which suture and when should it be taken out?
• Signature, printed name, and contact details.


The treatment of open wounds depends on:
• Depth and area
• Contamination
• Tissue loss (e.g. vascular, tendon, or nerve damage)
• Other (open fractures or joints, compartment syndrome).
Equipment
• Anaesthetic (local or general)
• Gloves, mask, and eye protection
• 2 x kidney dish (1 for cleaning solutions, 1 below the wound to collect used wash)
• 50mL syringe
• Swabs
• Forceps, scalpel, scissors
• Normal saline or antiseptic solution
• Sterile drapes.
Procedure
Wound cleaning
• Take swabs of wound for microbiology if visibly contaminated or history suggestive
• Clean wound with copious amounts of normal saline and/or water-based antiseptics using syringe
• Clean wound with swabs from the centre outwards to prevent further wound contamination:
• Do not use high-pressure irrigation (can push debris deeper).
Inspection and removal of gross contamination
• Photograph wound with adjacent ruler to document size
• Look for gross contamination and remove with forceps.
Deep palpation
• Methodically check each area visually and with deep palpation to avoid missing contaminants and tissue injuries
• Use forceps and wound retraction to examine all areas
• Look for any damage to blood vessel, nerves, and tendons
• Move the joints above and below the injury whilst looking at the tendon as it moves. D Tendon injuries are easily missed if the wound was incurred in a different position to the resting state (e.g. in clenched fist injury)

If deep tracts are palpated, the wound may need to be extended into the skin above it to allow adequate drainage.
Excision of dead tissue
• Cut away any dead tissue until healthy tissue is visible.
Maintaining drainage
• Any cavity must be adequately drained. In the emergency department, a wick is used rather than a drain
• Siting a drain:
• Identify the most dependent part of the cavity
• Use artery forceps to identify the depth of the tract
• With scissors, taper and cut a corrugated drain to fit into the tract
•Pass the tip of the forceps from the tract base so they can be seen at the skin surface
• Make an incision over the forceps to allow the drain to be sited
• Grasp the tip of the drain with the forceps and ease it into the wound
• To stop the drain dislodging, a loose suture can be placed into the skin and either around the drain or sutured through one of its corrugations. (This depends on the type of drain used.)
• Finally, wash the wound with antiseptic solution
• A pack can be placed into the wound and cavities, to keep small tracts open and allow drainage
• A loose suture can be placed to keep the pack in place.
• Contaminated wounds and bites should not be sutured closed due to high infection risk and the need for adequate drainage.
Dressing
• A non-stick dressing should be placed over the wound and edges, followed by gauze and bandage or tape
• Further wound inspection and debridement is required at 48-96 hours.
Examine sooner in heavily contaminated wounds.

Clinical Procedures - Backslabs 
​Plaster backslabs are used as immediate splints for fractures until definitive treatment is performed and are also used to protect the fracture fixation post-surgery.
Equipment
• Stockinette
• Padding:
• 10cm × 1 roll = above or below elbow backslab
• 15cm x 2 rolls = below knee backslab
• Plaster of Paris bandages
• Bowl or bucket of water (lukewarm, 25-35°C)
• Crepe bandage
• Scissors.
Risks
• Circulatory and nerve impairment, compartment syndrome, pressure sores, joint stiffness.
Procedure Tips
• Backslab application is a 2-person procedure
•  Ensure the plaster fits well. A loosely applied cast will not provide adequate splintage and can rub, causing soreness
• D Ensure the plaster does not cause constriction. In the early stages following fractures, the limb may swell, further restricting blood and nervous supply to the limb
• Ensure bony prominences are adequately padded.
Documentation
• Date, time, indication, informed consent obtained
• Neurovascular status of limb
• Procedure performed
• Plan of further management
• Patient given instructions to contact staff if they experience increasing pain, if extremities change colour (e-g. become blue), or develop 'pins and needles' or numbness
• Signature, printed name, and contact details.

Procedure: Below Knee
Used for fractures/dislocations at the ankle and fractures of the foot.
• Use a padded knee rest if available to hold the knee at an angle of 10-15°
• Hold the ankle at 90° with the foot in a neutral position
• Cut a length of the stockinette from just below the knee to the toes and apply onto the patient
• Apply a layer of padding over the stockinette:
• The padding should extend from just below the knee to
the toes
• Start the padding from one end, rolling it around the limb evenly, overlapping half of the previous turn each time
• Measure a slab of 10 layers of 15cm plaster of Paris from just below the back of the knee down to the base of the toes
• Fold the plaster slab and dip it into the water holding the ends
• Removed the plaster from the water, squeeze gently, and straighten it out
• Fan out the upper end of the slab to fit the calf area
• Place from just below the knee along the posterior surface of the lower leg, underneath the heel, and down to the base of the toes
• Mould and smooth the plaster to fit the contours of the leg with the palms of your hands
• Cut two side slabs 10 × 20cm long (length dependent on size of patient) made from 6 layers of plaster
• Dip these in water and apply either side of the ankle joint:
• A U-slab may be used instead of the side slabs. A 10cm wide U-slab (made of 6 layers of plaster) should be applied down one side of the leg under the heel of the foot and up the other side. Great care must be taken not to let the slabs overlap anteriorly
• Finally, turn the stockinette back over the top and bottom edges of the plaster.

Procedure: Below Elbow
Used for fractures/dislocations at the forearm (including
Colle's-type injuries) and fractures of the hand.
• Cut a length of the stockinette from just below the elbow to the knuckles; cut a small hole for the thumb
• Apply the stockinette to the patient
• Apply a layer of padding over the stockinette:
• The padding should extend from the elbow to the knuckles of the back of the hand and show the palmar crease, allowing flexion of the fingers
• The thumb should be completely free
• Start the padding from one end, rolling it around the limb evenly and overlapping half of the previous turn each time
• Cut a length of plaster from below the elbow to the knuckles from a plaster of Paris slab dispenser 15cm or
20cm wide (dependent on size of patient), or by forming a slab from 15cm or 20cm plaster of Paris bandage using 5 layers
• Fold the plaster and dip it into the water holding the ends
• Removed the plaster from the water, squeeze gently, and straighten it out
• Carefully position the slab on the limb over the padding from just below the elbow, down the dorsal surface of the limb to the knuckles
• Mould and smooth the plaster to fit the contours of the forearm with the palms of your hands
• Turn the stockinette back over the edge of the plaster cast at either end
• Finally, apply the roll of crepe bandage over the plaster and the overturned stockinette to hold the plaster in place as it sets.

Procedure: Above Elbow
Used for fractures/dislocations at the forearm and elbow, also supracondylar fractures of the humerus.
• Place the limb in a position of 90° flexion at the elbow
• Cut a length of the stockinette from the axilla to the knuckles of the hand; cut a small hole for the thumb
• Apply the stockinette to the patient
• Apply a layer of padding over the stockinette:
• The padding should extend from the axilla to the knuckles of the back of the hand and show the palmar crease, allowing finger flexion
• The thumb should be completely free
• Start the padding from one end, rolling it around the limb evenly and overlapping half of the previous turn each time
• Prepare a 10cm or 15cm plaster of Paris slab (dependent on patient size), using 5 layers. The slab should be long enough to extend from the axilla to the knuckles of the hand
• Fold the plaster and dip it into the water holding the ends
• Removed the plaster from the water, squeeze gently, and straighten it out
• Carefully position the slab on the limb over the padding running down the posterior surface of the limb over the back of the elbow
• Mould and smooth the plaster to fit the contours of the forearm with the palms of your hands
• Prepare two 10cm-wide slabs of 5 layers of 25cm length (adjust length according to size of patient). Place these on each side of the elbow joint to reinforce it
• Turn the stockinette back over the edge of the plaster cast at either end
• Finally, apply the roll of crepe bandage over the plaster and the overturned stockinette to hold the plaster in place as it sets.

​Clinical Procedures - Incision and Drainage
Equipment
• Mask, eye protection, and gloves
• Antiseptic solution and drapes
• Scalpel
• Microbiology swab
• Forceps
• Curette
• 2 x kidney dish (1 dirty, 1 for wash solution)
• 50mL syringe
• Swabs
• Normal saline
• Ribbon pack e.g. Aquacel®.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed written consent
• Position patient to allow easy access to abscess area
• Wear mask and protective glasses as the pus can be under pressure and spray!
• Clean hands with surgical scrub method and put on sterile gloves
• Clean and drape area appropriately
• Hold kidney dish below abscess to collect pus
• Make an incision with the scalpel over 'pointed' area or most fluctuant point of abscess:
• Try to incise along natural skin lines. This can be difficult when there is distortion of tissue due to abscess swelling
• Take microbiology swab of pus
• Extend incision to allow good drainage of the cavity
• Insert a gloved finger and gently break down any loculations
• Perform a curettage of the wound to remove the thick abscess capsule if present
• Excise any necrotic skin using forceps and scalpel

• Wash the cavity with normal saline until wash runs clear.
The volume needed depends on the size of the abscess
• Pack wound loosely with ribbon pack and apply dressing
• Clean area around the wound
• If the patient is systemically unwell, immunocompromised, or if cellulitis is spreading from the abscess area, a course of IV antibiotics will need to be given.
Follow-up
• The pack should be changed at 24 hours and the wound inspected
• If sending the patient home, ask district nurses or practice nurse to assess and change pack.
Documentation
• Date, time, indication, informed consent obtained
• Site and size of abscess, cellulitis, and observations
• Anaesthetic technique (e.g. local or general)
• Incision technique
• Findings (dimensions of cavity, loculations, amount of pus)
• Microbiology swab taken?
• Haemostasis achieved?
• Volume of wash solution used
• Type of pack used
• Follow-up instructions and antibiotics (if needed)
• Advice given to patient
• Signature, printed name, and contact details.

Indications
• Painful swollen area
• Spreading cellulitis
• Systemically unwell
• Failure of antibiotic treatment.
Contraindications
• Pulsatile swelling (e.g. false or true aneurysm).
Risks
• Spread or recurrence of infection, bleeding
• Scar
• Further surgery.
Procedures Tips
Necrotizing fasciitis/Fournier's gangrene
• Greatest risk in immunocompromised and peri-anal or scrotal wounds
• Possible signs include:
• Systemically unwell
• Rapidly spreading erythema ‡ skin necrosis
• Surgical emphysema
• Easy passage of finger between skin and fascia planes
• Yellowish-green necrotic fascia.
Perianal abscesses
• Perform a digital rectal examination feeling for a 'grain of rice' in the anal canal suggesting a fistula opening or bulge from a collection of pus
• Perform a rigid sigmoidoscopy looking for pus or rectal tumours
• If a fistula is suspected, probing for a tract may create false tracts
• Follow-up microbiology:
• If skin bacteria (e.g. S. aureus or S. epidermidis), the abscess is probably secondary to an infected skin follicle
• If gut bacteria, (e.g. E. coli), the abscess is probably due to an infected peri-anal gland. Increased chance of fistula formation and follow-up to check wound healing ‡ referral to colorectal specialist is advised.
Groin abscesses
• Suspect false aneurysm if the patient has been attempting IV injections at the site
• Check for pulsatility and request ultrasound to investigate further.