Clinical skills Flashcards
What is Corrigan’s sign?
Prominent carotid pulsation - sign of aortic regurgitation
What is De Musset’s sign?
Head-nodding in time with the heartbeat - sign of aortic regug
What is Mueller’s sign?
Pulsation of the uvula in time with the heartbeat - sign of aortic regurg.
What is Hill’s sign?
Higher blood pressure in the legs than the arms - sign of aortic regurg.
What is Quincke’s sign?
Nailbed capillary pulsation - sign or aortic regurg
What is Kussmaul’s sign?
Increase in JVP during inspiration. This occurs in pericardial constriction, right ventricular infarction or rarely, cardiac tamponade.
What are the causes of clubbing of the fingers?
Respiratory causes:
- Bronchial carcinoma
- Lung Fibrosis
- Bronchiectasis (supurative lung disease as in cystic fibrosis)
- Mesothelioma
Cardiovascular causes:
- Atrial myxoma
- Infective endocarditis
- Cyanotic heart disease
Gastrointestinal causes:
- Cirrhosis
- Inflammatory bowel disease
What are the causes of flapping tremor/ asterixis?
- Respiratory failure: e.g. COPD
- Hepatic failure: e.g. cirrhosis
- Renal failure
- Drug intoxication: e.g. phenytoin.
What are the causes of gynaecomastic?
- Cirrhosis
- Thyrotoxicosis
- Klinefelter’s syndrome
- Drugs: digoxin and spironolactone
How does the body stop postural hypotension from occuring in the healthy?
- On standing the blood has a tendency to pool in the lower limbs causing temporary hypotension.
- Baroreceptors in the aortic arch and carotid sinus detect this change and evoke a sympathetic response.
- This causes a rapid generalised venoconstriction, an increase in heart rate, and an increase in stroke volume, acting to restore cardiac output and blood pressure.
- In most people this response occurs before any awareness of hypotension, but a delay in this response can cause giddiness and pre-syncope.
What does vitamin A toxicity cause?
- Raised intracranial pressure causing headache, nausea, vomiting and visual loss
- Increased bone resorption causing osteoporosis and hypercalcaemia
- Liver damage
- Hair loss
- Skin changes
- Possible increased risk of malignancy, especially among smokers.
- Teratogen!!!!
What is the purpose of taking an ABG?
- Assess patient acid/base balance
- Assess patient for hypoxia and CO2 retention
- Initiate treatment as appropriate to treat imbalances
What are the indications for taking an ABG?
- Evaluation of adequacy of ventilation, oxygen carrying capacity of blood, and acid base levels
- To establish a diagnosis of, and severity or respiratory failure
- Patient management of: respiratory failure/dysfunction, renal/hepatic failure, poly trauma/multi organ failure, diabetic ketoacidosis, sepsis and burns, poisoning.
- Guide therapy in: oxygen administration, mechanical ventilation, alkali treatment
- Monitoring during major surgery
- Arterial cannulation: continuous pressure monitoring, frequent blood sampling, diagnostic angiography, therapeutic embolisation.
What are the contraindications for taking an ABG?
- Absolute:
- Positive Allen’s test
- Absent pulse at insertion site
- Evidence of infection or vascular disease involving selected limb
- Distal to surgical shunt – dialysis patient
- Consent
- Relative:
- Severe coagulopathy
- Anticoagulation agents
What is the Allen’s test? How is it performed?
A test used to determine whether the patency of the radial or ulnar artery is normal.
- The examiner thumbs over the radial and ulnar arteries and compresses them.
- The patient then opens the hand while pressure is maintained over the arteries.
- One artery is tested by releasing the pressure over that artery to see if the hand flushes.
- The other artery is then tested in a similar fashion.
What are the alternatives to taking an ABG?
- Pulse oximetry can give an indication of oxygenation but can be inaccurate, particularly in the setting of decreased oxygenation and/or perfusion.
What are the adverse effects of ABG sampling?
Complications are rare for needle arterial puncture – mostly related to arterial cannula insertion:
- Haematoma formation
- Sepsis
- Arterial thrombosis
- Arterial ischemia
- Arteriospam
- Vasovagal
- Pain
What is the clinical anatomy relevant to ABG collection?
What is an appropriate site selection for an ABG?
- Radial artery: has the benefit of collateral circulation
- Relatively close to the surface
- Relatively easy to palpate and stabilise
- Easily compressible post procedure
- Can be difficult to puncture due to small size, particularly in presence of low BP
- Increased risk of spasticity in artery than other sites
- Brachial artery:
- Large and easy to palate
- Only used when radial unsuccessful
- Degree of collateral circulation – not like radial
- Close proximity to nerves – can be punctured by mistake
- No underlying ligaments or bone to support compression – increased risk of haematoma/ bleeding
- Femoral artery:
- Good for low output states
- Large and easy to palpate
- Only use when radial unsuccessful
- Poor collateral circulation
- Greater infection rates
- Close to femoral vein which can be easily punctured.
What equipment is need to perform an ABG?
- Alcohol based hand rub (ABHR)
- Arterial blood gas syringe (pre‐heparinised syringe)
- 25g (23g if needed)
- Alcohol and chlorhexidine swabs
- Gauze swabs
- Dressing Tape
- Kidney dish
- Personal protective equipment (PPE), including Safety glasses, goggles or shield and clean gloves
Describe the procedure of an ABG?
- Assemble Equipment
- Wash Hands
- Ensure privacy
- Introduce self to patient
- Explain procedure to patient using appropriate language
- Obtain patient permission to perform procedure
- Perform Allens test
- Position patient – supporting proposed area of insertion
- Radial Artery – stabilize patient arm on pillow or use rolled towel under wrist for support – hyperextend wrist
- Brachial Artery – stabilize arm on pillow for support
- Femoral Artery – lie patient flat
- Place underpad under proposed puncture site
- Wash hands
- Apply gloves & goggles
- Palpate artery
- Cleanse intended insertion site with alcohol swab – allow to air dry
- Hold syringe in dominant hand – dart like fashion
- Locate artery with non dominant hand
- Insert needle at 45 degree angle to vein (5-10mm distal to finger over artery) while stabilizing artery with free hand, needle bevel up
- Observe for pulsating flow of blood into syringe indicating artery puncture (may feel POP as you enter artery)
- Allow syringe to fill against gravity
- Remove needle and syringe from artery
- Apply immediate pressure to puncture site (hold your finger there for 1 minute, then ask the patient to hold it for another 4 minutes)
- Expel air from syringe, apply airtight stopper to syringe, disposing of sharp appropriately
- Rotate syringe to allow heparin to mix
- Ensure patient comfort and safety prior to leaving bedside
- Appropriately label sample, and send for analysis
- Document procedure in patient record
What needs to be documented after an ABG has been performed?
- result of Allen’s test
- collection time
- puncture site used
- oxygen concentration and method of administration
- patient response to procedure
- site condition after completion of procedure (any complications)
- results of sample and any changes to therapy
What is the use of algorithms in acute cardiac life support?
- Algorithms are a form of flow diagram which illustrates a sequence of actions that should be undertaken in the emergency situation
- Several tasks within the algorithm may be done at the same time
- Algorithms are based on the facts that
- chance of successful defibrillation decreases with time, earlier defibrillation results in more successful outcomes
- effective CPR with minimal interruptions has been shown to improve patient outcomes
- there are certain interventions that are indicated in all forms of cardiac arrest
What are the reversible causes of arrest that need to be considered? 4 H’s and 4 T’s?
- Hypovolaemia
- Hyper /Hypokalaemia & other metabolic causes
- Hypoxia
- Hypothermia
- Toxins: drugs, overdose, caffeine
- Tension pneumothorax
- Thrombus - PE or MI
- Tamponade - cardiac
What are the shockable rhythms?
- Atrial fibrillation
- Ventricular fibrillation: VF is an asynchronous chaotic ventricular rhythm that produces no output. Most common mechanism of arrest is from myocardial ischemia or infarction.
- Ventricular tachycardia: Pulseless VT is a wide complex regular tachycardia with no detectable cardiac output composed of three or more ventricular beats with rate >100bpm.
- Torsade de points: Form of VT in which the QRS complexes appear to be constantly changing
What is asystole?
- Confirm asystole increase size of trace and/view in more than one lead, need to rule out fine VF
- Asystole represents the total absence of ventricular electrical activity, and therefore myocardial contraction
- Complete absence of electrical activity on ECG tracing
- Continue CPR while considering intubation, reversible causes and their treatment
- Transcutaneous pacing to be considered, if appropriate
What is pulseless electrical activity?
- Defined as the absence of a detectable pulse in the presence of electrical activity
- Presence of narrow electrical complexes indicates organised depolarisation through the myocardium, but no shortening of muscle fibres
- Narrow complex usually associated with profound hypovolemia, especially in multi trauma
- Board complex PEA observed in cardiac arrest are most likely due to massive MI and severe hyperkalaemia
- Consider cause and treat
What drugs are used in acute cardiac life support?
- Adrenaline
- Amiodarone
- Lignocaine
- Sodium bicarbonate
- Magnesium Sulphate
Describe the indications, dose, route, and adverse effects of the following drug when used in ACLS?
Adrenaline (all algorithms)
- Alpha 1 action causes peripheral vasoconstriction, redistributing blood flow to central circulation. This results in increased coronary artery perfusion and coronary blood flow
- Beta 1 action in heart increases strength of ventricular contraction (positive inotropic action) and increased heart rate (positive chronotropic action)
Indications
- whenever there is no effective spontaneous circulation not quickly reversed by DC shock, fluids or other rapid procedure
Dosage (Adult)
- 1mg IVI. Repeated every 3-5 minutes (every second cycle)
- may be made into infusion
Route
- IV
- IO
Adverse Effects
- Tachyarrhythmia’s
- Severe hypertension after resuscitation
- Tissue necrosis if extravasation occurs
Describe the indications, dose, route, and adverse effects of the following drug when used in ACLS?
Amiodarone (VT/VF)
- prolongs refractoriness of myocardial tissue
- also has weak Beta Blocker activity
Indications
- VF/VT which is unresponsive to defibrillation
- prophylaxis of recurrent VF/VT
Dosage (Adult)
- 300mg (5mg/kg) bolus diluted in 20 mls dextrose over 2 minutes
- further bolus 150mg could be considered
- infusion following bolus of 900mg/100ml D5W over 24 hours
Route
- IV (prolonged infusion requires central access
- IO
Adverse Effects
- hypotension
- bradycardia
heart block
Describe the indications, dose, route, and adverse effects of the following drug when used in ACLS?
Lignocaine (VT/VF)
- membrane stabilising antiarrhythmic which blocks cardiac sodium channels
- suppresses automaticity in the His-Purkinjee system and spontaneous depolarisation of the ventricles during diastole
Indications
- consider use in refractory VT/VF if amiodorone not available
- prophylaxis in recurrent VT/VF
- Should not be used in addition to Amiodarone, as an alternative only
Dosage (Adult)
- 1 – 1.5mg/kg IV bolus
- repeat doses 0.5ml/kg every 5- 10 minutes may be considered, up to 3mg/kg
- infusion 2-4 mg/min – not recommended until return of spontaneous circulation
Route
- IV
- IO
Describe the indications, dose, route, and adverse effects of the following drug when used in ACLS?
Sodium bicarbonate
- buffer agent which dissociates to sodium and bicarbonate, with hydrogen ions converts to carbon dioxide, which is then excreted by the lungs
- good ventilation best buffer for respiratory acidosis
Indications
- known acidosis
- hyperkalaemia
- overdose of tricyclic antidepressants
- protracted arrest (>15 minutes)
Dosage (Adult)
- 1mmol/kg over 2-3 minutes
- repeat doses of up to 0.5mmol/kg, at 10 minute intervals, as guided by ABG’s
Route
- IV bolus
- IO
Adverse effects
- alkalosis, hypernatraemia and hyperosmolality
- intracellular acidosis may worsen
- if mixed with adrenaline or calcium may inactivate one another, precipitate and block IV line
Describe the indications, dose, route, and adverse effects of the following drug when used in ACLS?
Magnesium sulphate
- membrane stabiliser – helps to maintain normal resting membrane potential
Indications
- torsades de Points
- cardiac arrest associated with digoxin toxicity
- documented hypokalaemia
- documented hypomagnesaemia
Dosage (Adult)
- 5mmols in IV bolus
Route
- IV
- IO
Adverse Effects
- with excessive use, may cause muscle weakness, paralysis, respiratory failure
What is the purpose of defibrillation?
Defibrillation aims to depolarise all cardiac cells at one time by the delivery of electrical current, with the hope that the interruption to an abnormal rhythm allows normal cardiac electrical activity to re-establish, and the SA Node recommence its role as dominant pacemaker
What are the indications for defibrillation?
- VT & VF
- these rhythms have chaotic electrical activity which does not provide adequate cardiac output, and can potentially be reversed by delivery of DC shock
- defibrillation is the only intervention that has been proven to increase survival in cardiac arrest patients with a shockable rhythm
- it is essential that shock be delivered as soon as possible, as delay in delivery of shock is directly related to the success of defibrillation
- Principles also apply to atrial fibrillation & flutter in the elective setting. In this instance the patient is sedated prior to the delivery of current.
What are the contraindications for defibrillation?
Patient who is DNR
What causes transthoracic impedance? What methods can be used to overcome this?
- the resistance to the flow of electrical current produced by the components of the thorax – bone, tissue, fat and muscle, which defibrillation energy must overcome to be effective
- methods to overcome impedance include
- use of large paddles
- use of gel and/or gel pads to ensure good contact
- positioning of paddles away from sternum – not over bone
- application of firm/even pressure through paddles
- consider removing excess hair from chest
What is the rationale for early defibrillation?
- the earlier defibrillation occurs, the more likely it will be successful
- with the inability of myocardium to store oxygen, over time as it becomes hypoxic and more ischemic it is less able to respond to shocks
- the only intervention of ACLS that has been proven to be effective
How do you place defibrillation paddles?
What is the difference between monophasic vs biphasic defibrillation?
- monophasic –current travels form one electrode to the other
- single shock of 360 joules used
- many institutions still have monophasic defibrillators
- biphasic – delivers current in two directions – one direction and then in reverse
- single shock of 200 joules used
- requires lower joules to be effective, benefit of less risk of damage to myocardium
- it is thought that the first part of the waveform reduces the excitation threshold for ischemic cells, preparing cells for the second part of the waveform
- TCH has biphasic defibrillators (ZOLL)
What is the procedure checklist for emergency defibrillation?
- Confirm need for defibrillation
- through monitoring leads or paddle check
- Apply gel pads appropriately on chest wall
- Operator positioned on patient’s right side
- Place defibrillator paddles over gel pads
- Charge defibrillator
- Call “Charging 200 joules”
- When defibrillator charged call “All Clear”
- Do visual sweep asking for items to be removed etc as required
- Confirm defibrillation still indicated
- Deliver shock
- Place paddles back into defibrillator
- Attach defibrillator monitoring leads if not already insitu
What is the purpose of airway management?
To ensure removal of obstruction to enable the provision of adequate ventilation and oxygenation to sustain all vital metabolic activities. Priority is to oxygenate and ventilate, not place a device.
What are the indications for airway management?
- respiratory/cardiac arrest
- semiconscious patient
- patient who is unable to control own airway (CVA, Drugs, Sedation)
What are the different aids that can be used to manage an airway?
- Oropharyngeal airway
- Nasopharyngeal airway
- Laryngeal mask airway
- Endotracheal tube
Describe how Yankear sucker and Y suction catheters are used?
Yankear sucker:
- Insert catheter into mouth along gum line to pharynx
- Move catheter around mouth until secretions cleared
- Clear tubing by suctioning up water
Y suction catheter
- Open catheter packaging
- Apply sterile glove to hand to touch catheter tip
- Apply lubricant to catheter
- Without applying suction gently and quickly insert catheter into nose or trachea (ETT) using slight downward slant
- If resistance felt – pull back 1cm and apply suction
- Apply finger over vent to create suction and slowly withdraw catheter while rotating between fingers
- Clear tubing by suctioning up water
- Discard catheter and glove
How are oropharyngeal airways inserted?
Procedure is carried out whilst wearing gloves and goggles
- Insert airway into mouth upside down – with the curve pointing upwards until it touches the roof of the soft palate
- Gently rotate airway 180 degrees and insert until flange sits on outer surface of lips
- once in place reassess for clear breath sounds and air entry
How are nasopharyngeal airways inserted?
Procedure is carried out whilst wearing gloves and goggles
- Lubricate airway well using water or water based lubricant
- Insert airway bevel up
- Rotate airway around as it is gently pushed posteriorly and down – not up
How are laryngeal mark airways inserted?
Procedure is carried whilst wearing gloves and goggles
- Check cuff and valve
- Leave full deflated
- Lubricate rear of device only, avoiding bowl of device
- Person inserting device positioned at back of patient, head of bed
- Insert into mouth, press mask upwards against the hard palate and advance into pharynx using index finger
- With head and neck flexed, press LMA into posterior pharyngeal wall using index finger
- When resistance felt tip of cuff is at upper oesophageal sphincter, ensure black line on LMA is facing upper lip, remove finger, inflate cuff
- Assess for air entry
- Secure LMA
How are endotracheal tubes inserted?
Procedure is carried out whilst wearing gloves and goggles: Maximum time allowed for attempt is 30 seconds.
- Ensure all equipment functioning effectively, including suction placed under right hand side of pillow
- Patient pre-oxygenated with 100% oxygen
- Leave pillow under head as it aids visualization
- In resuscitation wont need any drugs to paralyse or sedate – cold intubation
- Cardiac and saturating monitoring in place
- Laryngoscope inserted into mouth to view vocal cords
- Assistant passes operator ETT – tip down
- If stylet in place assistant removes as requested
- Once ETT in place assistant inflates cuff using 5-8mls of air
- Placement confirmed by:
- listening over lung field for air entry
- observing for bilateral rise and fall of chest
- cricoid assistant felt tube pas through cords
- fogging of the ETT
- use of ETCO2 monitoring
- Secure ETT
Describe the algorithm used to determine the aetiology of ascetic fluid.
What physical exam manoeuvres can be used to detect ascites?
How do you prepare the patient for an ascetic tap?
1. Patient/Relative Informed Consent and Time Out (see above)
- Have the patient urinate prior to the procedure.
- Have the patient’s head angled at 45-60. This will allow the bowel to rise to the top, leaving the lower quadrants full of fluid.
- Adjust the height of the bed so that you are most comfortable.
- Choose a location:
- There is some new evidence that midline below the umbilicus may in fact be vascularized and carries higher risks of complications due to the location of the bladder.
- The right and left lower quadrants have been shown to give better yield; 5 cm superior and medial to the anterior superior iliac spines on either side
- Avoid any abdominal scars, superficial wounds, large sub-epigastric veins. Tap out the area of the belly to confirm dullness.
- Some authors suggest to avoid the LLQ due to potential splenomegaly while others recommend avoiding the RLQ as the cecum is a “fixed” retroperitoneal structure.
- One should do a careful physical exam to look for splenomegaly before considering the LLQ.
- Mark the spot of dullness with and inverted pen cap or needle cap. If there is any uncertainty, obtain or perform a ultrasound.
Clear the area of gowns, pillows, patient hands, and prep the patient.
Describe the relevant anatomy for where jugular venous access would occur?
The essential surface anatomy is comprised of the borders of Sedillot’s triangle. The sternal head of the sternocleidomastoid muscle medially, the clavicular head of the sternocleidomastoid laterally, and the superior border of the medial third of the clavicle inferiorly. Cannulation begins with cutaneous puncture at the superior apex of this triangle.
The internal jugular vein courses from the apex of the triangle toward the base, parallel to the long axis of the body. The carotid artery courses in a similar direction but is medial and deep to the internal jugular vein. Identifying the pulsation of the carotid artery before beginning is mandatory.
Describe the relevant anatomy for an infraclavicular venous access?
The axillary vein courses medially to become the subclavian vein as it passes anteriorly to the first rib. After crossing the first rib, the vein lies posterior to the medial third of the clavicle at the change in curvature of the clavicle. Deep to the vein is the anterior scalene muscle followed by the subclavian artery.
The “break” of the clavicle represents the most appropriate course for the needle, passing immediately beneath the junction of the medial one-third and lateral two-thirds of the clavicle. The appropriate point for cutaneous puncture lies 1–2 cm inferior and lateral to the clavicular transition point.
Describe the relevant anatomy for in insertion of a femoral catheter?
Femoral venepuncture is performed in the anterior superior thigh, just below the level of the inguinal ligament. This ligament runs from the pubic tubercle medially to the anterior superior iliac spine laterally. The femoral artery generally bisects the inguinal ligament. The femoral vein lies immediately medial to the femoral artery. Cutaneous puncture is performed approximately 1 cm medial to the point of maximal pulsation of the femoral artery. As with cannulation of the internal jugular vein, venepuncture of the femoral vein can be facilitated by realtime ultrasound localization.
It is critical to ensure that the puncture of the vein occurs below the level of the inguinal ligament, ie, meaning the skin insertion point should be slightly inferior on the thigh. Puncture above the inguinal ligament may lead to needle or catheter entry into the abdominal compartment or haemorrhage into the retroperitoneal space.
What are the P,Q, R, S, J, S, T waves/segments/points of the ECG indicating?
P Wave
- atrial depolarisation
- precedes every QRS complex
- rounded and upright
PR Interval
- duration 0.12 – 0.20 seconds
- short duration indicates impulse originating elsewhere in the atria than the AV node
- prolonged duration indicates conduction delay
QRS Complex
- ventricular depolarisation
- falls after every P wave
- duration 0.06 – 0.10 seconds
Q wave – first negative deflection after P wave
R wave – first positive deflection after P wave
S wave – first negative deflection after R wave
J Point
- point marking the end of the QRS complex, and the beginning of the ST segment
ST Segment
- represents the end of ventricular depolarisation and the beginning of repolarisation
T Wave
- ventricular repolarisation
- follows S wave
- typically rounded and upright
QT Interval
- ventricular depolarisation and repolarisation
- duration 0.36 – 0.44 seconds
- duration rate dependent
U Wave
- recovery of purkinjee fibres
- not always present
- rounded and upright
QRS Variations
large deflections are labelled with an upper case, small deflections are labelled with a lower case letter
Explain the layout of a 12 lead ECG
- Septal leads are V1-V2
- Anterior leads are V3-V4
- Lateral leads are V5-V6, I, aVL
- Inferior leads are II, III, aVF
Describe the anatomy of a vein?
Blood vessels are hollow tubules that have three separate layers within their walls- the tunica intima, tunica media and adventitia or externa.
- Tunica intima: innermost layer of arteries and veins, closest to blood, lined with endothelial cells
- Tunica media: made of muscle fibres, allows for dialation/constriction.
- Tunica adventitia: outer layer made of fibrous tissue and elastic fibres.
Describe the anatomy of the lumbar spine, what layers need to be passed to reach the subarachnoid space?
Skin and subcutaneous tissue → supraspinous ligament → Interspinous ligament → ligamentum flavum → posterior epidural space → dura → subarachnoid space.
How is an appropriate site selected for a lumbar puncture?
- Flexing of the back widens the space between adjacent spinous processes and laminae, allowing a needle to be passed.
- Puncture at L3-L4 or L4-L5 interspaces – both these spaces are below the termination of the spinal cord in most adults
- L3-L4 identified by palpating tip of both iliac crests, line joining the most superior part of both crests will intersect midline at L4 process or L4-L5 interspaces.
