(2-15-17) Venipuncture Sedation Complications & Common Office Emergencies Flashcards
what is the indwelling catheter?
the plastic part that stays in your arm after you remove the needle
what does the gauge of a needle refer to?
the external diameter of the needle
**it is the number of needles that can be placed into a 1inch circle
*therefore the lower the gauge the larger the size of the lumen
what is the highest gauge needle used for?
acupuncture (30)
what gauge needle is used for local anesthesia?
25, 27
What are the 4 different types of solution for IV administration?
- lactated ringers
- sodium chloride
- 5% dextrose in water
- sterile water for injection
what are the most commonly used sizes of solution?
250, 500, 1000 mL
what things should you check before administering the solution?
- is the fluid clear
- expiration date
- sealed?
- any doubt about sterility
what is the adult infusion rate set at?
10 drops = 1 mL
can be adjusted if a person needs more
what is the pediatric infusion rate set at?
60 drops = 1 mL
when applying a touniquet, where should it go?
2 - 6 inches above intended site
when applying a touniquet, what should still be palpable after applying?
brachial artery
radial artery
when applying a touniquet, what knot should you tie it with?
slip knot
when applying a touniquet, what stimulates blood flow?
pumping fist
do you have to wear gloves when you tie a touniquet? what about when you clense the site?
- tourniquet = no
- clensing = yes
what are the steps in placing the needle?
- hold the skin taught
- position the needle for insertion (10-30 degrees)
- insert the needle and look for blood (stop at blood)
- advance the needle or catheter
- apply pressure over tip and remove needle from catheter
- connect infusion tubing
- secure by taping (or tegaderm)
- immobilize the elbow
how should you position the needle for insertion?
10-30 degrees to plane
-BEVEL UP
what could cause slow or non running fluids?
- bag too close to heart level
- bevel of needle against wall of a valve
- tourniquet left of the arm
- infiltration
- tube kink
what is a venospasm?
- protective mechanism due to stimulation
- the vein may disappear or collapse
- occasionally accompained by painless sensation
*occurs more in apprehensive pts due to the high release of catecholamine
who does venospasms affect more?
occurs more in apprehensive pts due to the high release of catecholamine
what might help if your pt experiences a venospasm?
-heat (may help the vein to reappear)
what is a hematoma?
- extravasation of blood into surrounding interstitial spaces
- painless, bluish discoloration
- not always preventable
what should you do if your pt experiences a hematoma?
- remove tourniquet to dec venous pressure
- apply ice: VC
- subsequential management: heat can be applied no less than 4 hours
how is an air embolism prevented?
- eliminating air bubble from the tubing
- rule of thumb: pt can tolderate up to 1 mL/kg of air in the venous circulation without adverse affect
- children are more significant
if your pt gets an air embolism, how do you manage that?
attempt to prevent air from entering the cerebral or pulmonary circulation by:
- adjusting the patient/chair
- head down and lying on the left
for what kinds of pts is over-hydration very significant for?
- heart failure pts
- children
*can cause pulmonary edema, respiratory distress, tachycardia, inc BP
what is the best way to prevent over-hydration?
calculate fluid deficit and how many hrs the pt NPO (?)
what does the extravasation of drugs cause?
- pain (does not migrate up or down the arm)(localized to needle tip)
- delayed drug absorption
- tissue damage (diazepam and pentobartal)
what is the management for extravasation of drug?
- remove the needle, apply pressure if less than 2mL of drug has leaked
- if more than 2 mL of drug has leaked, 1% procaine in a fan type injection
what local complication of drug administration is considered an emergency?
intra-arterial injection
*chemical insult: spasm that will compromise distal circulation, chemical endarteritis: lead to thrombosis and ischemia
where is intra-arterial injection most common to happen?
medial aspect of the antecubital fossa where the brachial artery is superficial
what is the best way to recognize an intra-arterial injection?
- prevention is the most important feature to avoid this
- assess the blood color (bright cherry red = bad)
- look for pulsatile flow in the tubing with every heart beat (arterial pressure will rise following removal of the touniquet)
- severe pain will radiate peripherally from the site outwards to the hands or fingers (unlike extravasation)
- absence of radial pulse
- molted skin color
- cool limb
- GANGRENE
what is the management of intra-arterial injection
- leave the needle in place
- give 1% procaine
- hospitalize the pt (sympathetic nerve block)
- surgical endartecomy
- heparinization
- amputation of the gangrenous limb if treatment failed
- hyperbaric oxygen
what are some local venous complications?
- phlebitis: inflammation of the veins
- thrombophelbitis: inflammation of the vein wall have preceded a thrombus formation
- pain and tenderness
- edema
- delayed onset
what are the causes for local venous complications?
- pH
- needle mechanical irritation
- venipuncture technique (size related to lumen)
what is the management for local venous complications?
- limit limb activity (sling)
- elevate the limb
- moist heat for 20 min TID
- NSAIDS
- conditions worsen –> vascular surgery
what are the potential causes for a pt to experience nauseau and vomitting?
- swallowing blood
- OPIODS
- hypoxia
what is the management of nausea alone?
give O2 + IV antiemetic
*Zofran
what is the management of vomitting alone?
- stop tx immediately
- turn pt to RIGHT side
- suction the mouth
- IV antiemetic
*Zofran
what is the most common cause of airway obstruction?
- prolapsed tongue
* other causes: foreign bodies, debris
what are some maneuvers to establish and maintain airways?
- head tilt chin lift/jaw thrust
- use of airway adjuncts as necessary
- if obstruction other than tongue, identify and remove foreign objects
what does the head tilt chin lift do?
- displaces the prolased tongue from the posterior pharyngeal wall
- eliminates obstruction
intended as an improved alternative to the traditional face mack
-minimizes trauma
laryngeal mask airway
what are the indicators to use a laryngeal mask airway?
- alternative airway
- difficult airway
- cant ventilate
- failed intubation
- can’t move head or neck
- no laryngoscope
what are the advantages to using a laryngeal mask airway?
- minimal training
- shortest placement time
- can use in PEDIATRIC pts
- least amount of tissue trauma
- can use to intubate
is a double lumen airway that is blindly inserted that is used to ventilate pt regarless of tracheal or esophageal placement
combitube
what is the most secure airway you can get?
tracheal intubation
what is a laryngospasm?
partial or complete closure of vocal cords due to direct irritation of cords by foreign matter during light planes of anesthesia
what unique thing occurs with laryngospasm?
“crowing” noise
*inc respiratory effort with difficulty exchanging air
how would someone manage a laryngospasm?
- terminate procedure: back off surgical sites
- deliver 100% O2
- position head
- protrude tongue, and suction oro, nasal, and hypopharynx
- push on chest, listen for rush of air
- if unsuccessful, 0.5-1.0cc of Succinylcholine IV or sublingually
- 100% positive pressure O2 by face mask, support ventilations until pt able to spontaneoulsy ventilate
- watch for bradycardia or other rhythm disturbances
is hypo or hyper-glycemia more dangerous?
HYPO
what is the normal blood glucose level
70-110 mg/dl
what occurs when the bodys blood glucose level falls to 50-70? what about 20-50?
50-70 = CNS becomes excitable (inc neural activity) extremenervousness, sweating and treambling
20 - 50 = convulsions, loss of consciousness, shock
what is in our kit as dentist to raise blood sugar if it gets too low?
glucogon
what is the management of a hypoglycemic pt if they are still conscious?
-recognition of hypoglycemia
-oral carbs
-monitor
-permit pt to recover
If no response, oral IV 50% dextrose
-get assistance
what is the management of a hypoglycemic pt if they are unconscious?
- get help
- BLS (ABC’s) O2
- monitor vitals
- definitive care
- -administer carbs
- -50% dextrose
- -glucagon 1mg IM
what is an allergy?
- hypersensitive state
- acquired through exposure and then re-exposure to a particular antigen
- results in a heightened/exaggerated response of the immune system
- has a broad range of onset
- –delayed 48hrs
- –immediate
what are the 4 commonly used drugs with allergic potential?
- antibiotics
- analgesics
- antianxiety drugs
- local anesthetics
allergies affect multiple organ systems, but primarily the…
- skin (most common)
- respiratory system (after skin but before CVS)
- CVS
- GI tract
*if HYPOtension is involved then leads to anaphyplactic shock
when does an allergy lead to anaphylactic shock?
when HYPOtension is involved
what is the main issue of an allergy on the CVS system?
angioedema of the larynx
what is the management of allergic reactions?
*easier to avoid than treat
- good initial hx
- what drug was used
- what happend
- –clinical manifestations, onset of symptoms, rate of pregression
- what tx was required
what are the symptoms of anaphylactic shock?
- progressive respiratory and circulatory failure
- itching of the nose and hands
- flushing of the face
- feeling of substermal pressure
- labored breathing, stridor, coughing
- sudden hypotension
- cyanosis
what is the management for a pt what goes into anaphylactic shock?
- get help
- postion pt (BLS)
- oxygen
- monitor pulse and vitals
- establish IV access if necessary
- epi 0.1mg IV
- antihistamines and steroids
- transfer to hospital
what is medelson’s syndrome?
-vomit -> aspirate -> die
what are the major factors to control in regards to aspiration?
- amount of gastric fluid
- pH of gastric fluid
- presence of solid debris
what is the management of aspiration?
- observe for signs of potential emesis (swallowing, diaphoresis (sweating) , heaving)
- position pt, suction readily available
- seek out medial attention when aspiration strongly suspected
what causes intrinsic asthma?
allergy; antigen-antibody response
what causes extrinsic asthma?
- infection
- exercise
- irritating inhalants
- emotional stress
- anxiety
what is the managment of a pt with asthma?
- position pt
- administer bronchodilator
- 100% O2 by face mask
- monitor pt
- if not resonsive, epi subcutaneously (0.3mg q30-60 min)
- activate EMS
what do you give for a pt with an Opiod overdose?
- naloxone (Narcan)
- supplied as 0.4mg/mL add 3 mL of saline
- give 0.1 mg slowly as assess the response
-monitor for one hour in the office
what do you give for a pt with benzodiasepine overdose?
- flumzenil (Romazicon) 0.1 mg/mL
* give an initial dose of 0.2mg with subsequent doeses administered as needed to a max dose of 1mg
what are the clinical manifestations of angina?
- sudden onset with exertion (sub-sternal pain)
- squeezing, choking, burning, pressing, tightness (heavy weight on chest)
- radiation to NECK, JAWS, TEETH, SHOULDER
what is the management of a pt with angina?
- terminate procedure
- position pt
- supplemental O2
- administer nitro
- reevaluate
what is a myocardial infarction?
- deficient coronary blood supply to myocardium
* leads to cellular death and necrosis
what are the clinical manifestations of a myocardial infection?
- may occur at rest, after excercise, or emotional stress
- sudden onset, pain is prolonged
- described as crushing, substernal pain
- NOT relieved by NITRO
- nausea, vomiting, cold perspiration
- weakness, dizziness, palpatations
what is the management of an MI?
- terminate procedure and all painful stimulation
- initiate EMS (time is now an issue)
- basic action plan
- –position pt
- –place monitors
- –keep a record of events
MONA
what is MONA in reference to an MI?
- Morphine
- Oxygen
- Nitro
- Aspirin
