Ch. 19 Procedures & Skills Flashcards
What are the two approaches for pericardiocentesis?
Parasternal and subxiphoid approach
What type of needle should be used for pericardiocentesis?
7.5- to 12.5-cm 18-ga needle or Intracath needle
Describe parasternal approach for pericardiocentesis.
■ Insert needle perpendicular to the skin in the left fifth or sixth intercostal
space 1 cm lateral to the sternum.
■ Avoid area of internal mammary artery, which lies 3-5 cm from the sternal
border.
Describe the subxiphoid approach to pericardiocentesis.
Insert needle 1 cm inferior to the junction of the xyphoid process and left
costal margin at a 30°-45° angle to the skin aiming toward the left shoulder
How deep should the needle go during pericardiocentesis?
about 6-8 cm beneath the skin in
adults and < 5 cm in children.
Which pericardiocentesis is recommended for the blind approach?
subxiphoid approach
Where is the needle insertion site for upright thoracentesis?
along the mid-scapular or posterior axillary line
1-2 intercostal spaces (ICS) below the
upper level of effusion but NOT below the eighth intercostal space
What size blade should be used for thoracotomy?
20
Where is the initial thoracotomy incision made?
between 4th and 5th rib
(just inferior to nipple in men, inframammary fold for women)
Where does the incision for thoracotomy begin and end?
sternum to posterior axillary line
What is the indication for aortic crossclamping if no tamponade exists?
SBP <70 mmHg
What are initial pacing generator settings?
Rate 80 BPM or 10 BPM above intrinsic rate
Output = minimum. Increase current output until capture (then adjust to 10% above this level)
How should you confirm cardiac pacing is successful?
Electrical capture seen on the monitor, CHECK FOR A PULSE, and improved perfusion
What are two contraindications to transvenous pacing?
- severe hypothermia
- Prosthetic tricuspid valve
How does the current differ between transcutaneous vs transvenous pacing?
transcutaneous usually requires 40-60 mA
transvenous usually require 2-3 mA
How does the use of ultrasound improve central line placement?
increase the rate of successful first
puncture and patient satisfaction, while
decreasing the number of attempts,
time to perform the procedure, and
complication rate.
For IJ central line placement, where does the IJ typically lay in relation to carotid artery?
The vein usually lies anterior and lateral of the carotid artery just deep to the SCM muscle at the level of the thyroid cartilage
What is the preferred site of IO placement in adults?
proximal humerus
Describe the location of tibia IO placement.
Anteromedial surface, approximately 1-3 cm (2 finger widths) below the tuberosity on the medial, flat surface of the tibia
Describe the location of humerus IO placement.
Over greater tubercle with arm in adduction (1 cm above surgical neck)
How is correct IO placement confirmed?
Aspiration of blood or marrow contents confirms position.
also:
- The needle’s ability to stand upright without support
- fluids that infuse easily without evidence of swelling or extravasation
How many arteries vs veins are in the umbilical stump?
2 arteries, 1 vein
Describe the location and characteristics of the umbilical artery.
The vein is located at 12 o’clock and is thin walled with a large lumen
Describe the location and characteristics of the umbilical vein.
The paired arteries are located at 5 and 7 o’clock and have thick walls with smaller
lumens
How long after birth does the umbilical vein remain patent?
1-2 weeks after birth
How far should umbilical vein catheter be advanced?
Advance the catheter 1-2 cm beyond the point at which good blood return is obtained (~4-5 cm in a term newborn)
What size catheter should be used for umbilical artery catheterization?
3.5-5 Fr
What is the course the umbilical vein catheter travels as seen on XR?
travels cranially in the umbilical vein to the IVC
What is the course the umbilical artery catheter travels as seen on XR?
travels down toward the pelvis, makes a posterior turn into the common iliac artery
then continues cranially with the tip
ending in the aorta either between T6 and T9 or between L3 and L5 vertebral
bodies to avoid the celiac, superior mesenteric, and renal arteries
What test should be performed prior to radial artery cannulation?
Allen test
How is Allen test performed?
Compress radial and ulnar arteries, have patient open and close fist 10x. Have patient then open hand, then release ulnar artery compression. If the hand becomes flushed. Cap refill <6 seconds = positive test and okay to cannulate radial artery
What is the textbook site of entry for paracentesis?
- 2 cm below the umbilicus in the midline or
- 4 -5 cm cephalad and medial to the ASIS in the RLQ or LLQ
When doing paracentesis, which vessel should be avoided and where is it located?
inferior epigastric artery
Runs from the midpoint of the inguinal ligament to the umbilicus
What ascites fluid lab value is considered presumptive SBP while cultures are pending?
> 250 PMN/μL (polymorphonuclear
leukocytes) aka neutrophils
For rectal foreign body removal, how is perianal nerve block performed?
Infiltrate anesthetic circumferentially around the anus in the submucosal tissue.
What is the dispo for a patient concerned to have possible perforation after rectal foreign body removal?
observe for 12 hours; if there is perforation or deep mucosal tear –> admit
How should NG tube be measured for length?
tip of xiphoid to earlobe to tip of nose +15 cm
How should NG tube be guided into the nose?
along floor of nose, under inferior turbinate
How long must a G tube have been placed in order to be able to replace it in ED?
usually >3 weeks
How should the patient be positioned for gastroesophageal balloon tamponade?
HOB at 45 degrees
What are the two types of gastroesophageal balloons and how do they differ?
- The 3-lumen Sengstaken-Blakemore (SB) tube (gastric balloon, esophageal
balloon, and gastric aspiration port) - The 4-lumen Minnesota tube (which adds an esophageal aspiration port)
How much volume should be used to inflate the blakemore and minnesota tubes gastric balloon respectively
usually 250-300 mL for SB tube, 500 mL for Minnesota tube
What pressure sure esophageal balloon be inflated to during blakemore/minnesota tube placement?
30-45 mmHg
How are thrombosed hemorrhoids removed?
- prone or lateral decubitus
- local anesthesia
- Using forceps to grasp skin overlying thrombosis, excise an elliptical shaped
piece of skin overlying the clot. Incision should be directed radially from anal orifice. Remove the clot. - +/- packing (allow to fall out over 24 hours)
Where is LP needle placement in adults?
L2-L3 to L5-S1 interspaces in adults (cord ends at L2 in adults)
Where is LP needle placement in infants?
L4-L5 or L5-S1 in infants (cord ends at L3 level at birth)
What is normal LP opening pressure in adults?
7-20 cm H2O in adults
What is normal LP opening pressure children <8 years old?
1-10 cm H2O
When should perimortem cesarean delivery be considered?
in any woman who suffers a cardiac
arrest after 24 weeks’ gestation and is unresponsive to brief resuscitation
If age of gestation is not known, how can it be estimated based on fundal height?
height of fundus from symphysis pubis in centimeters = gestational age
In pregnant women with cardiac arrest
and unknown gestational age, if the
fundus of the uterus is palpated above
the umbilicus, assume that the fetus is
viable.
C-section performed within __ minutes of mother’s death usually results in an excellent neonatal outcome
5
Where is the incision made for perimortem cesarean delivery?
A midline vertical incision is made through the abdominal wall extending from the symphysis pubis to the umbilicus and carried through all abdominal layers to the peritoneal cavity
then,
A small (~5 cm) vertical incision is made through the lower uterine segment until amniotic fluid is obtained or until the uterine cavity is clearly entered. Extend this incision with blunt scissors to the uterine fundus. Deliver fetus
What is maximum dose of lidocaine without epi?
3-5 mg/kg
What is maximum dose of lidocaine WITH epi?
7 mg/kg with epinephrine
What is the dose of IV lipid emulsion for CNS/cardiac toxicity due to anesthestics?
For CNS/cardiac toxicity, administer 20%
IV lipid emulsion 1.5 mL/kg as bolus,
may repeat 1-3 times and then start
0.25 mL/kg/min infusion.
Describe the location of infiltration for a mental nerve block.
1-2 mL anesthetic to foramen below the
second mandibular premolar (just medial
to pupil in sagittal plane when looking
straight ahead)
Describe the location of infiltration for an infraorbital nerve block.
2-3 mL anesthetic, insert needle in
mucosa adjacent to upper second
bicuspid and direct toward foramen
on inferior border of infraorbital ridge
(a depth of approximately 2.5 cm)
Describe the location of infiltration for a posterior superior alveolar nerve block.
Distal to the distal buccal root of the upper
second molar toward maxillary tuberosity
at depth of 2-2.5 cm
(above gums of upper posterior molars)
Describe the location of infiltration for an inferior alveolar nerve block.
1-2 mL anesthetic, in the pterygomandibular triangle, at a point that is 1 cm above the occlusal surface of the molars
(medial to bone)
What does of fentanyl may cause chest wall rigidity?
> 5 ug/kg
Where should needle be inserted for elbow arthrocentesis?
A 22-ga needle is inserted in depression in center of triangle formed by radial head, lateral epicondyle and olecranon and directed medially.
Where should needle be inserted for shoulder arthrocentesis?
A 20-ga needle is inserted at a point inferior and lateral to the coracoid process and directed posteriorly toward the glenoid rim
Where should needle be inserted for knee arthrocentesis?
An 18-ga needle is inserted at the midpoint or superior portion of the patella and directed between the posterior surface of the patella and the intercondylar femoral notch
Where should needle be inserted for ankle arthrocentesis?
A 20- to 22-ga needle is inserted at a point just medial to the anterior tibial tendon
and directed inward at the anterior edge of the medial malleolus. The
needle must be inserted 2-4 cm to penetrate the joint space.
When checking anterior compartment of the lower leg, where should needle enter?
1 cm lateral to the anterior border of the tibia to a depth of 1-3 cm
What are indications for escharotomy?
■ Clinical evidence of elevated compartment pressures indicative of compartment
syndrome in burned extremities. This procedure is typically performed
in circumferential burns.
■ Circumferential burns of the torso or neck resulting in impaired ventilation
or tracheal obstruction.
How should eschars be removed from limbs?
Incise over the medial and lateral aspects of the affected area.
Extend incision 1 cm proximal to the burn and 1 cm distal to the area of injury. Take care to avoid vasculature and vital nerves
How should eschars be removed from chest?
Patients should be intubated and ventilated. Incise from the clavicle to the costal margin on the anterior axillary line bilaterally.
This may be joined by transverse incisions over the subcostal margin
How should eschars be removed from chest?
Incise laterally and posteriorly to avoid jugular veins and carotid arteries.
What is the point of entry for suprapubic catheterization?
Point of entry is 2-4 cm above the pubic symphysis, in the midline of abdomen
