Clinical skills Flashcards

Question

What are the shockable rhythms?

Answer 1

* 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

Answer 2

* ***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

Answer 3

* 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](https://wattlecourses.anu.edu.au/mod/quiz/view.php?id=769007) * Board complex PEA observed in cardiac arrest are most likely due to massive MI and severe hyperkalaemia * Consider cause and treat

Answer 4

* Adrenaline * Amiodarone * Lignocaine * Sodium bicarbonate * Magnesium Sulphate

Answer 5

* 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

Answer 6

* 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

Answer 7

* 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

Answer 8

* 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

Answer 9

* 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

Answer 10

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

Answer 11

* 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.

Answer 12

Patient who is DNR

Answer 13

* 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

Answer 14

* 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

Answer 15

* 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)

Answer 16

* 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

Answer 17

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.

Answer 18

* respiratory/cardiac arrest * semiconscious patient * patient who is unable to control own airway (CVA, Drugs, Sedation)

Answer 19

* Oropharyngeal airway * Nasopharyngeal airway * Laryngeal mask airway * Endotracheal tube

Answer 20

Yankear sucker: 1. Insert catheter into mouth along gum line to pharynx 2. Move catheter around mouth until secretions cleared 3. Clear tubing by suctioning up water Y suction catheter 1. Open catheter packaging 2. Apply sterile glove to hand to touch catheter tip 3. Apply lubricant to catheter 4. Without applying suction gently and quickly insert catheter into nose or trachea (ETT) using slight downward slant 5. If resistance felt – pull back 1cm and apply suction 6. ![]() Apply finger over vent to create suction and slowly withdraw catheter while rotating between fingers 7. Clear tubing by suctioning up water 8. Discard catheter and glove

Answer 21

Procedure is carried out whilst wearing gloves and goggles 1. Insert airway into mouth upside down – with the curve pointing upwards until it touches the roof of the soft palate 2. Gently rotate airway 180 degrees and insert until flange sits on outer surface of lips 3. once in place reassess for clear breath sounds and air entry

Answer 22

Procedure is carried out whilst wearing gloves and goggles 1. Lubricate airway well using water or water based lubricant 2. Insert airway bevel up 3. Rotate airway around as it is gently pushed posteriorly and down – not up

Answer 23

Procedure is carried whilst wearing gloves and goggles 1. Check cuff and valve 2. Leave full deflated 3. Lubricate rear of device only, avoiding bowl of device 4. Person inserting device positioned at back of patient, head of bed 5. Insert into mouth, press mask upwards against the hard palate and advance into pharynx using index finger 6. With head and neck flexed, press LMA into posterior pharyngeal wall using index finger 7. When resistance felt tip of cuff is at upper oesophageal sphincter, ensure black line on LMA is facing upper lip, remove finger, inflate cuff 8. Assess for air entry 9. Secure LMA

Answer 24

Procedure is carried out whilst wearing gloves and goggles: Maximum time allowed for attempt is 30 seconds. 1. Ensure all equipment functioning effectively, including suction placed under right hand side of pillow 2. Patient pre-oxygenated with 100% oxygen 3. Leave pillow under head as it aids visualization 4. In resuscitation wont need any drugs to paralyse or sedate – cold intubation 5. Cardiac and saturating monitoring in place 6. Laryngoscope inserted into mouth to view vocal cords 7. Assistant passes operator ETT – tip down 8. If stylet in place assistant removes as requested 9. Once ETT in place assistant inflates cuff using 5-8mls of air 10. 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 11. Secure ETT

Answer 25

Procedure is carried out whilst wearing gloves and goggles 1. Identify cricoid and thyroid cartilages 2. Place thumb and middle finger on either side of cricoid cartilage, fingers together and index finger above, in space between cartilages 3. Apply pressure directly backwards 4. Release pressure only at direction of intubator

Answer 26

Diagnostic tap: * New-onset ascites: Fluid evaluation helps to determine etiology, differentiate transudate versus exudate * Suspected spontaneous or secondary bacterial peritonitis Therapeutic tap: * Symptomatic treatment of tense ascites

Answer 27

Absolute contraindications 1. An acute abdomen that requires surgery. 2. Fibrinolysis or DIC. 3. Refused consent Relative contraindications Using ultrasound to document ascites and to guide the site of aspiration may be prudent in several of the conditions listed below. 1. Severe thrombocytopenia (platelet count \< 20 X 10³/μL) and coagulopathy (international normalized ratio [INR] \>2.0). Patients with an INR greater than 2.0 should receive fresh frozen plasma (FFP) prior to the procedure. 2. Loculated fluid or intra-abdominal adhesions 3. Abdominal wall cellulitis at the site of puncture 4. Distended bowel/ bowel obstruction/ ileus/distended urinary bladder 5. Pregnancy 6. Uncooperative patient

Answer 28

* Inform the patient of reason for the procedure, proposed benefits and potential complications * Explain the major steps of the procedure

Answer 29

# 1. Patient/Relative Informed Consent and Time Out (see above) 2. Have the patient urinate prior to the procedure. 3. 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. 4. Adjust the height of the bed so that you are most comfortable. 5. Choose a location: 1. 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. 2. 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 3. Avoid any abdominal scars, superficial wounds, large sub-epigastric veins. Tap out the area of the belly to confirm dullness. 4. 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. 5. One should do a careful physical exam to look for splenomegaly before considering the LLQ. 6. 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.

Answer 30

1. Observe universal precautions with regard to handling of needles and body ﬂuids. 2. Prepare skin around and at site selected for puncture with povidine or alcohol solution using sterile gauze. Drape the puncture site to form a sterile ﬁeld. 3. Draw up local anesthetic and administer subcutaneously and into the soft tissue at the puncture site using a 5-ml syringe and 25-G needle. Switch to the longer 20-G needle and administer 4-5 mL of lidocaine along the catheter insertion tract. Always aspirate while advancing the needle deeper into the soft tissue. 4. Use the No. 11 scalpel blade to make a small nick in the skin to allow an easier catheter passage. 5. Insert the needle directly perpendicular to the selected skin entry point. Slow insertion in increments of 5 mm is preferred to minimize the risk of inadvertent vascular entry or puncture of the small bowel. Continuously apply negative pressure to the syringe as the needle is advanced. Upon entry to the peritoneal cavity, loss of resistance is felt and ascitic fluid can be seen filling the syringe. At this point, advance the device 2-5 mm into the peritoneal cavity to prevent misplacement during catheter advancement. 6. Use one hand to firmly anchor the needle and syringe securely in place to prevent the needle from entering further into the peritoneal cavity. 7. Use the other hand to hold the stopcock and catheter and advance the catheter over the needle and into the peritoneal cavity all the way to the skin. If any resistance is noticed, withdraw the device completely and reattempt insertion. While holding the stopcock, pull the needle out. The self-sealing valve prevents fluid leak. 8. Attach the 60-mL syringe to the 3-way stopcock and aspirate to obtain ascitic fluid. Use the 3-way valve, as needed, to control fluid flow and prevent leakage when no syringe or tubing is attached.

Answer 31

* Protein, albumin (used with serum albumin to obtain serum-ascitic albumin gradient), specific gravity, glucose, bilirubin (may be elevated in bowel perforation; biliary leak), amylase (elevation – pancreatic source), lipase, triglyceride (elevation – chylous ascites; lymphatic leak), LDH * Cell count and differential * Bacterial culture, Gram stain, acid fast bacilli, fungal * Cytology * pH

Answer 32

* Failed attempt to collect peritoneal fluid * Persistent leak from puncture site * Wound infection * Abdominal wall haematoma * Spontaneous haemoperitoneum * Hollow viscus perforation (small or large bowel, stomach, bladder) * Catheter laceration and loss in abdominal cavity * Laceration of major blood vessel * Hypotension * Hepatorenal syndrome

Answer 33

1. Patient consent 2. Indications for the procedure 3. Relevant labs e.g INR, Platelet count 4. Procedure technique, sterile preparation, anaesthetic used, amount of fluid obtained, character of fluid, estimated blood loss 5. Complications during the procedure

Answer 34

* Alternative venous access when peripheral access is difficult * Administer IV fluids * Administer medications that should not be used peripherally, for example * Inotropes * Vasopressors * Chemotherapy * Administer total parenteral nutrition, * To permit haemodialysis & plasmapheresis * As a portal for temporary cardiac pacing * Obtain blood samples * Central venous oxygen saturation * Historically used to measure the CVP as a guide to fluid resuscitation. (More recently has been called into question)

Answer 35

Because CVC may be lifesaving there are no absolute contraindications. A risk-benefit analysis will need to be undertaken to advise the decision to proceed. * Inexperienced operator * Un co-operative patient * Uncorrected bleeding diathesis or anti-coagulation The following factors may also preclude insertion in particular sites. * Skin infection over insertion site * Pneumothorax or haemothorax in the contralateral lung. * Distorted local anatomy or presence of previous surgery * Previous radiation therapy * Suspected proximal vascular injury

Answer 36

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%, which include; * Malposition * Haematoma, Haemorrhage * Pneumo/haemothorax * Cardiac tamponade * Arterial Puncture * Emboli * air * catheter * thrombotic * Dysrhythmia * Infection * Death

Answer 37

* Internal Jugular * Subclavian * Femoral veins

Answer 38

Ultrasound

Answer 39

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.

Answer 40

1. The patient is ideally placed in a 15° head-down (Trendelenburg) position to ensure filling of the subclavian vein. (Some patients with high central venous pressures do not tolerate this position well and should be monitored carefully during the procedure). 1. The right internal jugular vein is often preferred because of 2. The relatively straight pathway to the superior vena cava, while the left internal jugular vein joins the left subclavian vein at an approximate right angle that is sometimes difficult to negotiate. 3. The apex of the left lung rises more cephalad than the right, increasing the risk of pneumothorax on the left. 2. Also, injury of the thoracic duct is more common with left internal jugular catheterization attempts. 3. The operator is positioned at the head of the bed, and the patient's head is turned away from the site to be cannulated. 4. The operator identifies the triangle described above, formed by the medial and lateral portions of the sternocleidomastoid muscle and the clavicle. The clavicle serves as the base of the triangle. 5. The skin is punctured at the apex of the triangle, and the needle is directed caudally at a 45° angle to the frontal plane and slightly laterally toward the ipsilateral nipple. The needle is advanced to a depth of 3-5 cm depending on the patient's size and anatomy.

Answer 41

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.

Answer 42

1. The central approach to the internal jugular vein also begins with Trendelenburg positioning. 2. A towel roll often is placed vertically beneath the patient along the thoracic spine to help lower the patient's ipsilateral shoulder, thus better exposing the subclavian vein. 3. The operator is positioned at the side of the bed, and the patient's head is turned away from the site to be cannulated. 4. The skin is punctured approximately 1 cm caudal to the junction of the medial and middle thirds of the clavicle. The needle is advanced beneath the clavicle parallel to the frontal (horizontal) plane and directed toward the sternal notch. The angle of the needle should never dip below the frontal plane; this increases the risk of entering the pleural space, thus predisposing the patient to pneumothorax. The needle is advanced to a depth of 3-5 cm depending on the patient's size and anatomy.

Answer 43

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.

Answer 44

1. Femoral vein cannulation begins with the patient in a supine position with the legs slightly abducted. 2. The operator is positioned on the side of the bed. 3. The skin is punctured 1-2 cm below (caudad to) the inguinal ligament and approximately 1 cm medial to the femoral pulse. 4. The needle is directed cephalad and advanced at an approximate 45° angle. 5. The needle is advanced to a depth of 3-5 cm depending on the patient's size and anatomy

Answer 45

1. Once the vein is entered, the needle is then immobilized with the free hand and the syringe removed from the needle. 2. The operator's thumb is quickly placed over the needle hub to decrease the risk of air embolism. Some needle/syringe kits are designed to allow placement of the guidewire directly through the syringe without removing it. 3. The guidewire is then advanced into the vein. Minimal to no resistance should be met. Guidewires placed from the internal jugular or subclavian sites are long enough to reach the heart and may cause ectopy, necessitating careful attention to electrocardiographic monitoring and depth of guidewire insertion. 4. When the guidewire is in place, the needle is withdrawn from the insertion site while the guidewire is held motionless. 5. A scalpel and dilator are used to open the skin and dilate the subcutaneous tissue. 6. Using a rotating motion, the operator advances the catheter over the guidewire to the predetermined depth. 7. The guidewire is then removed, and free flow of venous blood from the catheter lumen is confirmed. Each lumen should then be aspirated and flushed. 8. The catheter is secured to the skin with suture or staples, and a sterile dressing is applied.

Answer 46

* Confirmation: chest x-ray to confirm tip is in the correct position. Should lie in the superior vena cava. Pneumothorax should be excluded for jugular and subclavian line insertion. * Care if the line: * Dressing the central line and the insertion site * Daily review: always use hand hygiene, checking for erythema, drainage, tenderness, redness, swelling, and suture and dressing integrity. * Routine replacement does not reduce or prevent infection of the central line.

Answer 47

To assist in the diagnosis of abnormalities in heart rhythm, rate, regularity, perfusion, size and positioning of chambers, and to assess the effects of drugs and devices used as part of treatment regimes.

Answer 48

* Chest pain * Syncope * Shortness of Breath * Pre operatively as part of workup * Sudden deterioration in condition for unknown cause * Routine review of cardiac conditions

Answer 49

* Provides a complete view of the electrical activity in the heart * With ECG are able to look at heart from unique angle, enhancing sensitivity to a particular region of the heart * Enables more in-depth analysis of arrhythmia and its origin * **ALWAYS RELATE ECG TO PATIENTS CONDITION** * Try to compare to old ECG’s

Answer 50

* No absolute contraindications to ECG – however initial treatment of life threatening arrhythmias take priority over acquisition of ECG tracing * Refusal by patient

Answer 51

No real alternative as such, however, there are other methods which provide continuous measurement: * Cardiac monitor in hospital * Holter monitor – mobile recorder of rhythm over period of time

Answer 52

* Local skin irritation from ECG electrodes * Consider patients emotional concern over findings

Answer 53

* Automaticity – ability of cell to generate electrical impulse (therefore any cell can be pacemaker – good to maintain a rhythm, bad due to arrhythmia formation) * Excitability – ability of cell to respond to an electrical impulse * Conductivity – ability of a cell to transmit an electrical impulse from one cell to another * Contractility – ability of cell to shorten and lengthen its muscle fibres * Extensibility – ability of a cell to stretch

Answer 54

**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

Answer 55

* It is essential that ECG’s are clearly labelled with patient details. This can be achieved by entering patient details in machine when obtaining ECG – preferred method – or in an urgent situation a patient label can be immediately attached to the printed ECG. * If ECG abnormal, actions taken should be documented in patient record.

Answer 56

1. Rate: 1. Tachycardia or bradycardia 2. Normal rate is 60-100/min. 2. Pattern of QRS complexes 1. Regular or irregular? 2. If irregular is it regularly irregular or irregularly irregular? 3. QRS morphology: 1. Narrow complex – sinus, atrial or junctional origin. 2. Wide complex – ventricular origin, or supraventricular with aberrant conduction 4. P waves: 1. Absent – sinus arrest, atrial fibrillation 2. Present – morphology and PR interval may suggest sinus, atrial, junctional or event retrograde from the ventricles. 5. Relationship between P waves and QRS complexes: 1. AV association (may be difficult to distinguish from isorhythimic dissociation) 2. AV dissociation: 1. Complete – atrial and ventricular activity is always independent 2. Incomplete – intermittent capture 6. Onset and termination: 1. Abrupt – suggest re-entrant process 2. Gradual – suggests increased automaticity 7. Response to vagal manoeuvres: 1. Sinus tachycardia, ectopic atrial tachydysrhymthmia – gradual slowing during the vagal manoeuvres, but resumes on cessation. 2. AVNRT or AVRT – abrupt termination or no response 3. Atrial fibrillation and atrial flutter – gradual slowing during the manoeuvre 4. ![]() VT – no response.

Answer 57

* Septal leads are V1-V2 * Anterior leads are V3-V4 * Lateral leads are V5-V6, I, aVL * ![]() Inferior leads are II, III, aVF

Answer 58

* The assessment and supplementation of patient fluid intake when required, as determined by clinical assessment. * To address the issues of appropriate IV device placement, clinical assessment of volume status, prescribing and administration of IV fluids and electrolytes.

Answer 59

Maintenance therapy – replaces the ongoing losses of water and electrolytes under normal physiological conditions. Goal is to preserve fluid and electrolyte balance. * Usually when patient not expected to be able to eat or drink for a prolonged period of time Replacement Therapy– corrects any existing water and electrolyte deficits. * Any increase in physiological processes require additional replacement therapy (eg. fever, sweating, diarrhoea, polyuria, burns, tachypnea) * Must always consider renal function, and any underlying severe cardiac or hepatic dysfunction

Answer 60

_Crystolloids (Normal Saline, Ringers, Dextrose 5%)_ * Solution of water with dissolved crystals * Wide variety of solutions with various dissolved particles to meet varying patient needs * Rapidly diffuse across cell membrane providing intracellular hydration * Cheap, store well, good fluid (not blood) replacers Hypotonic (Dextrose) * Fewer dissolved particles than plasma, therefore lower osmotic pressure. * Suitable for medication delivery, not fluid replacement as most of the fluid will leave the intravascular space Hypertonic (5% Dextrose in Ringers, 10% Dextrose, 5% Dextrose & 0.45% Saline) * Have more dissolved particles than plasma, therefore higher osmotic pressure. Initial effect of drawing water from intracellular to intravascular space. * Note: Most only hypertonic due to high sugar content, once this is metabolised no longer hypertonic Isotonic (Normal Saline, Ringers Lactate) * Roughly same dissolved particles are plasma. * Good all purpose choice for medication delivery and fluid replacement * Approximately one third remains in intravascular space one hour after administration → 3L required to replace 1L blood – with remaining issue of loss of red blood cells _Colloids (Whole Blood, Plasma, Packed Red Blood Cells, Plasma substitutes – Dextran, Gelofusion)_ Contain proteins or other molecules of high molecular weight resulting in them remaining in the intravascular space for long periods of time. By exerting osmotic pressure, they draw interstitial and intracellular water towards the intravascular fluid compartment. * Superior for blood loss replacement as remain in intravascular space and in the case of whole blood or red blood cells, have oxygen carrying capacity * Expensive, scarce, don’t store well, require cross matching * Blood component therapy should only be initiated when the expected benefits to the patient outweigh the potential hazards * Decision to transfuse RBC’s should be based on clinical assessment of the patient and their response to any previous transfusion as well as their haemoglobin level

Answer 61

Opening the consultation: * Introduce yourself * Confirm parents & childs details: name and DOB * Establish why present, check understanding & ask what they want to find out: * WHy have you come into the clinic today? * What would you like to know about the vacciantion programme? WHat do you already know? * Is there anything particular that concerns you regarding the vaccination? Exaplanation: * Vaccinations help protect children from serious disease & also provide protection for society as a whole (herd immunity). * "The vaccination programme is very safe, and almost all babies will have them. The reason for vaccination is both to protect your child from harm, and the community as a whole" * "Giving a child a vaccination against a disease dramatically lowers the risk of them catching the illness which could be extremely harmful to them both in the short and long-term. By stopping the disease developing in your child, we also stop your child being able to spread the disease, so it can be considred a public health benefit too. The aim is to immunise enough people that we can stop the disease completely - this happened with smallpox in some countries" * Check understanding: * Does everything I've said so far make sense?" * Do you have any questions? What to expect on vaccine day: * Explain normal reactions & measures the carer can take: * Its normal for the baby to cry and be upset during and after the injection, they may be a little more irritable for 48 hours afterwards, and may have a bit of a temperature. If this happens there are a few things you can do - ensure baby keeps up their fluids, and you can give some panadol. in about 1 to 10 children, the place of injection can be a bit red and sore for a day or so, this can also be relieved by panadol, some reassurance and a cold compress may help" * Explain more extreme reactions which may occur: * "If there is a large swelling at the site of injection, or you notice any rashes or swelling elsewhere (especially around the lips and mouth) it is important to contact the doctor urgently. Very occasionally, a child may have an adverse reaction to the vaccine and may have a temperature that does not respond t panadol or a seizure. If this happens contact the hospital." * "Complications of vaccines are very rare (less than 1 in 1000, and anaphylaxis in less than 1 in 500,000). Complications of the disease which we are vaccinating against are common and often serious, and that is why we feel it is for hte best to iimunise children." But what about MMR, doesn't that cause autism? * Explain the study which was conducted, and the new evidence that has come to light since: * There was a piece of research published a number of years ago, claiming a link between MMR and autism. Since its release it has been discredited - the research was on a very small group of individuals and the outcomes were biased by several factors. The research has since been withdraw and the research have been struck off." Rounding up: * Summarise the topics covered * Check parental/carer understanding and elicit any concerns * Offer an information leaflet on the relevant vaccinations * Arrange follow-up/schedule vaccination appointments * Thanks the parents/patient

Answer 62

* Bordetella pertussis: Inactivated bacteria * Diphtheria: Inactivated bacterial toxin * Polio: Inactivated virus * Haemophilus influenza B: Polysaccharide extract * Human Papilloma Virus: live attenuated * Measles/Mumps/Rubella: live attenuated vaccine * Pneumococcus: polysaccharide * Rotavirus: live attenuated vaccine * Tetanus: Inactivated bacterial toxin * Varicella: live attenuated

Answer 63

Introduction: * Introduce yourself * Wash hands * Confirm patient details: name/DOB * Check patients understanding of their inhaler Explanation: * Explain what the inhaler device is... * "You have been started on...(name of inhaler)... for your asthma/COPD" * Explain when the inhaler device should be used... * _Preventer:_ it helps to reduce the swelling in the airways and stops them from being so sensitive. You use this to lower the risk of severe attacks. I would like you to inhale ..(x puffs)..(xtimes a day)...everyday. It's really important that you don't miss doses, as regular use is key to keeping your asthma/COPD under control. Alway rinse mouth after use if the inhaler contains a steroid due to risk of oral candidiasis)." * _Reliever_:This is useful to help relieve immediate wheezing/asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn't need this more than 3 times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puffs) when you feel short of breath." * If you prescribe SMART (Syymbicort Maintenance and Reliever Therapy) regime. * "Symbicort is used as both a preventer and a reliver. You need to use this regularly... (x puffs)...twice a day to prevent the symptoms and...(x pudds).. each time you have an attack. Always rinse mouth after use due to risk of oral candidiasis." Demonstration: * Explain the steps below as you demonstrate * Prepare the inhaler - tkae off the lid/ shake if meter dosed inhaler/insert capsule if handihaler. * Load the dose - press button to puncture capsule if handihaler/press lever once if accuhaler/twist bottom if turbohaler. * Breathe out gently as far as is confortable. * Tighly seal lips around the mouthpiece. * Breathe in: * Dry powder inhaler need to be breathed in quick and deep * Metered dose inhalers need to be breathed in slow and deep * Soft mist inhalers need to be breathed in slow and deep * Remove inhaler from mouth, hold breath for as long as is comfortable. * Repeat procedure as directed Asses inhaler technique * Ask the patient to carry out the procedure themselves while you abserve. * Most patients technique will require tweaking * Point out the positives... then introduce room for improvement. Spacer devices: * Used to improve drug deposition to the lungs * Prepare inhlaer (Shake aerosol inhlaer) * Attach inhaler mouthpiece to the spacer device * Breathe out gently as far as is comfortbale * Seal lips around the spacer mouthpiece * Release 1 dose into hte spacer device * Breathe in and out through the spacer mouthpiece several times * Administer second dose if needed and finish * The spacer device should be washed with detergent (washing up liquid is fine) once a month and left to air-dry. It should never be wiped dry as this can cause static within the device and drug particles will stick to sides of hte spacer as a result. Spacers should be replaced at least once a year. Close the consultation * Ask if the patient has any questions or concerns * Provide information leaflet if available * Advise the patient to get in touch should they have any more questions or concerns * Thank patient * Wash hands

Answer 64

To drain and decompress the bladder. Drainage can be collected in an external collection bag

Answer 65

* Measurement of output in critically ill or comatose patients * Sensitive indicator of renal perfusion * Aim for urine output of \>0.5 ml/kg/hr * Obstruction to urine flow (prostate enlargement) * Surgical repair of bladder, urethra, and surrounding structures * Prevention of urethral obstruction from blood clots * Continuous or intermittent bladder irrigations * Long term management of patients with spinal cord injuries, neuromuscular degeneration, incompetent bladders * Severe Urinary retention * Wounds etc irritated or contaminated with urination * Urine specimen collection – “in-out” catheter * Terminal illness when toileting/linen changes painful for patient

Answer 66

Absolute * Urethral [Trauma](https://wattlecourses.anu.edu.au/mod/quiz/view.php?id=769007) (usually due to pelvic fractures) * Evidenced by blood in meatus, scrotal haematoma, high riding prostate * high suspicion of urethral tear needed * must perform retrograde urethrography * do not insert IDC if urethral injury confirmed Relative * Consent * Male – female, female – male catheterisation * Allergies – latex * Confused/aggressive patients * Pathology which may prevent advancement of catheter * Strict hygiene care needed

Answer 67

* Uridomes in male patients (condom catheter) * Suprapubic catheterisation (SPC) * Bladder retraining & incontinence pads * Intermittent catheterisation * Strict monitoring of output – need compliant/continent patient

Answer 68

* type and size of catheter inserted * amount of water in balloon * patient response to procedure * assessment of urine * any tests ordered * date catheter due for change/removal

Answer 69

* Catheter Pack * Cleansing solution – Normal Saline 60ml * Lubricant (with lignocaine for male catheterisation) * Catheters x 2, appropriate size and type * Underpad * Sterile gauze * 10ml syringe * 10ml sterile water * Urine drainage bag * Sterile gloves * Safety goggles * Clean Gown * Securing tape * Sterile specimen jar, if required

Answer 70

* Explain procedure to patient, obtain consent and **ensure privacy** * Wash hands. Prepare equipment * Raise bed to the appropriate height * Position the patient: * Female – recumbent with knees drawn up and soles of feet together * Male – supine with legs extended * Place procedural underpad beneath the buttocks Wash hands. Don sterile gloves (separate) then gloves from catheter pack * Remove the protective cover from the tip of the catheter _ONLY_. Lubricate, leaving the catheter cover in place * Check the inflation of the balloon by injecting the required amount of sterile water into the balloon port. Leave the syringe attached **(Manufacturer does not recommend balloon check)** * Place the catheter in (and anaesthetic gel for male) the dish **Female Catheterisation** * Using a clean swab each time, cleanse the labia majora using downward strokes * Separate the labia with free hand, using gloved hand * Cleanse the labia minora and urethral meatus * Discard forceps and first pair of gloves. Drape patient with fenestrated sheet to establish sterile area * Separate the labia with free hand * Maintain the separation until the catheterisation is complete * Place the dish containing the catheter between the patient's thighs * Identify the urethra * Ask the patient to take a deep breath to relax the sphincter * Gently insert the catheter tip 4 to 5 cm into the orifice using the sterile catheter sleeve. **Note: Do not use force** * Remove the sterile catheter sleeve and drain urine into the dish **Male Catheterisation** * Drape the genital area around the penis * Cleanse the shaft of the penis * Hold the penis with the non‐dominant hand. Retract the foreskin if present. * Clean urethral meatus and glans * Position fenestrated drape to provide sterile field * Insert local anaesthetic gel into the urinary meatus * Wait three minutes before continuing the procedure * Position the dish containing the catheter on the patient's thighs * Holding the penis vertical to the body, insert the catheter into the urethra. * Advance catheter to its maximum distance (up to the side arm of the balloon inflation port) and observe for urine flow. **ALERT:** If resistance is felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask the patient to attempt to void in order to relax sphincter * Inflate the balloon and gently withdraw the catheter until resistance is felt **Female/Male** * Collect sterile urine specimen if required * Inflate the balloon with the required amount of sterile water (see balloon hub) * Remove the protective cap from the urinary drainage bag, seal outlet tube and attach to the catheter * Drain 600ml only then clamp for one (1) hour * Male – reposition foreskin if required * Leave the patient comfortable * Lower the patient’s bed * Discard equipment. Wash hands. * Record the procedure in the patient's clinical record * Record output, clarity, colour and odour on the patient's FBC * Record if a specimen is sent to pathology * Watch for haematuria and diuresis in‐patients with chronic urinary retention * Adjust the Nursing Care Plan to indicate IDC insitu and associated peri toilets required for hygiene needs.

Answer 71

Medication delivery * Can't take oral form * Drugs unsuitable for gastric route * Uncooperative / seizing patient * Immunization

Answer 72

* PVD – potential for impaired absorption * Impaired coagulation, thrombolytic’s * AMI – affect on pathology tests * Site issues – scars, burn, oedema, lesion etc

Answer 73

* Deltoid: \<3ml * Dorso gluteal: \<5ml * Vetnrogluteal: \<5ml * Vastus lateralis: \<5ml

Answer 74

* Kidney dish – tip sharp form into bin – do not reach n for sharp * Medication (NaCl) * Syringe 3ml * Drawing up needle – decrease irritant effect of medication as passes through tissues an savoids recapping * Admin needle 23G * Alcohol swab – not always used in practice – immunizations * Gauze / cotton swab * GLOVES * Medication chart in real life

Answer 75

* Patient * Drug * Dose * Route * Time

Answer 76

Common indications for IV cannulation are: * Administration of blood and blood products * IV medications * Fluid replacement * Diagnostic agents

Answer 77

* Cannulation in a vein that has been accessed within the previous 24 hours * Accessing on the same side as: * mastectomy * vein graft * burn site * AV fistula * infection or inflammation * lymphadenopathy * oedema * thrombosis * CVA (affected side)

Answer 78

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.

Answer 79

* To obtain a sample of cerebrospinal fluid for diagnostic testing. * Can also be utilised as a port of access for the delivery of agents. * Measure pressure within the subarachnoid space.

Answer 80

* Suspected involvement of the meninges by infection or malignancy * Documentation of subarachnoid haemorrhage * Diagnosis or exclusion of infections or inflammatory conditions involves brain or spinal cord * Documentation or treatment of intracranial hypertension * Therapeutically to allow the delivery of chemotherapy, antibiotics and anaesthetic agents

Answer 81

* Absolute: * Intracranial mass lesion, especially if rapidly progressing * Anticoagulation or bleeding diatheses * Infection at site of suspected lumbar puncture * Signs of cerebral herniation * Focal neurologic signs * Relative: * Cardiorespiratory compromise – due to risk of increased compromise from positioning required for procedure. * Previous lumbar surgery

Answer 82

* Post lumbar puncture headache * Local or referred pain * Bleeding * Brain herniation – occurs several hours after procedure as a result of a continuous CSF leak through defect made by needle * Infection * Spinal herniation with cord compression * Development of intraspinal epidermoid tumour

Answer 83

Skin and subcutaneous tissue → supraspinous ligament → Interspinous ligament → ligamentum flavum → posterior epidural space → dura → subarachnoid space.

Answer 84

* 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.

Answer 85

* Local anaesthetic: * 1% lignocaine * Infiltrate local anaesthetic subcutaneously- any more may distort structures and make procedure more difficult * Deeper structures are less sensitive to pain * Consider use of sedation and/or systemic analgesia * Lumbar puncture tray * Sterile technique: * Areas cleaned with betadine * Drape with sterile drapes * Correct gowning and gloving and maintenance of sterile field paramount. * Educate patient as to post procedure care

Answer 86

* Clinical should be at eye level of patient back – limits parallax error * Preferred position is left lateral recumbent position with knees and head flexed – pillow under head (needed for pressure measurements) * Ask patient to try and touch knees to nose – flexes back as far as possible * Patient back as close to edge of bed as possible * Alternatively seated position with head flexed * Better for unwell patients * Increased risk of post puncture headaches * Patients back as close to edge of bed as possible with spine and pelvis vertical to bed.

Answer 87

* Assemble Equipment * Wash Hands * Ensure privacy * Introduce self to patient * Explain procedure to patient using appropriate language * Obtain patient permission to perform procedure * Set up sterile field * Position Patient * Left Lateral Position on bed * Pillow under head – head and knees flexed * Patients back as close to edge of bed as possible * Expose patients back * Assess landmarks accurately * Don sterile gloves and gown * Clean patient skin using betadine * Drape patient back appropriately * Position self and equipment appropriately * Reassess landmarks and identify region to be anaesthetised * Infiltrate anaesthetic agent appropriately * Assess location puncture to be performed * Insert needle into L3-L4 interspace * Superior aspect of spinous process lying inferiorly to space to be entered – midline * Advance needle gently to obtain CSF sample * When fluid appears connect 3 way stopcock and manometer * Measure pressures and obtain sample as needed * Reinsert stylet prior to removing needle * Remove needle gently – applying pressure over site * Advise patient of post procedure care * Document procedure appropriately

Answer 88

* Indication for procedure * patient positioning for procedure * skin preparation used * anaesthetic agent used * needle type and size used * pressure obtained * appearance of CSF * patient response to procedure * dressing applied * tests requested – results