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Capstone > Clinical Skills Mishmash > Flashcards

Clinical Skills Mishmash Flashcards

1
Q

Which is more medial, IJ or carotid?

A

IJ more medial than carotid

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2
Q

when placing subclavian CVC, what landmarks do you use?

A

Insert needle where medial and middle thirds of clavicle meet

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3
Q

Seldinger technique overview

A
  • needle, flash
  • remove syringe/occlude needle with finger
  • insert guidewire
  • remove needle
  • Incise skin
  • Insert dilator, remove
  • insert catheter over guidewire
  • remove wire
  • aspirate/flush ports
  • suture catheter in place
  • CXR to confirm
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4
Q

MC complication of CVC

A

pneumothorax

also vascular issues, infection, dysrhythmia, nerve injury, other thorax issues, etc.

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5
Q

CVC

- pro and con of IJ

A
  • Advantages: bleeding easily recognized, rarely malpositioned, less pneumothorax risk, ease of US guidance
  • Disadvantages: patient discomfort, risk of carotid artery puncture
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6
Q

CVC

- pro and con of subclavian

A
  • Advantages: most comfortable for conscious patient, good for hemodynamic measurements (L), lowest infection risk (R)
  • Disadvantages: highest risk of pneumothorax, can’t perform on intubated patient, can’t perform if <2 y/o, vein is not compressible
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7
Q

CVC

- pro and con of femoral vein

A
  • Advantages: easy to locate (NAVEL), 0% chance of pneumothorax, best for emergencies/CPR
  • Disadvantages: highest risk of infection, risk of DVT due to immobilization, not good for ambulatory patients
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8
Q

LP indications

A
  • CNS Infections: meningitis, encephalitis, myelitis
  • Inflammatory Processes: MS, Guillain-Barre, vasculitis
  • Subarachnoid Hemorrhage: confirmation of suspected acute injury
  • CNS Analysis: cytology/specific proteins, malignancy/paraneoplastic syndromes, metabolic conditions
  • Therapeutic Needs: to relieve high ICP symptoms, cryptococcus meningitis, idiopathic intracranial hypertension
  • Delivery of Meds: anesthesia, chemotherapy, antibiotics, contrast dye for myelogram
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9
Q

LP Technique

A
  • iliac crest to spinous processes: should be about L4
  • betadine and drape
  • anesthetic: subcut and then deep as possible
  • set up: manometer on stopcock, collection tubes, etc.
  • Needle (bevel always to pt’s side) into L3-L4 or L4-L5 space
  • “pop” then stop, check for CSF by removing stylet. If none, rotate needle
  • Attach manometer, measure opening pressure
  • Collect manometer CSF
  • Collect CSF from body until get 4 tubes
  • Reinsert stylet, ensure bevel is towards pt’s side
  • deep inhale and remove
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10
Q

LP complications

A

a. Backache: 33% of patients will have this, may be constant or intermittent
b. Headache: 10-30% of patients will have this, worsens with upright/improves with laying flat, beings 24-48 hours after LP and can last up to 2 weeks
c. Transient radicular pain
d. Bleeding: at site of needle insertion, can be due to epidural hematoma development
e. Paraparesis: risk increased with patients on anticoagulation agents
f. Infection/brain herniation (rare)

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11
Q

Equipment and materials for MSK injections

A
  • betadine/alcohol
  • 22 gauge, 1 1/2 inch needle
  • corticosteroid
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12
Q

Indications for knee joint injection

A
  • OA

- other noninfectious inflammatory issues

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13
Q

Indications for subacromial joint injections

A
  • rotator cuff syndrome
  • shoulder impingement
  • subacromial bursitis
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14
Q

MSK injection: appropriate dose of lidocaine and steroid

A 
Small joint (intraphalangeal)
- 1/2 ml ea lidocaine and steroid
Medium joint (ankle, wrist, elbow, heel, yes tendon/bursa)
- 1 ml ea lidocaine and steroid

Lrg joint (knee, hip, shoulder)

  • 1 ml steroid
  • 4 ml lidocaine
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15
Q

Corticosteroid injections

- pros

A
  • inexpensive,
  • easy to administer,
  • often provide quick and long-lasting relief of pain dt arthritis, tendonitis, bursitis, etc.
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16
Q

Corticosteroid injections

- frequency

A
  • some disagreement.

- Best rule is no more than every 4 months, max duration 3 years.

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17
Q

Corticosteroid injections

- sterile technique

A

inside of joint or tendon sheath is similar to an abscess cavity, poor circulation, easy to grow infections (esp bc cortisone can reduce immune system)

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18
Q

Corticosteroid injections

- systemic effects

A
  • Very small amount absorbed. DM might experience 1-2 day increase in blood sugar levels
  • Others: facial flushing, tachycardia, dysphoria.
  • Tx with antihistamine
  • Steroid flair: intense burning or aching pain at injection site. Usu 1-2 days but can be severe, consider narcotic pain relief
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19
Q

Corticosteroid injections

- MC used

A

kenalog

depo-medrol

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20
Q

Corticosteroid injections

- which preparation to use

A
  • suspension: should be cloudy or have a chalky end

- NOT solution which is clear as water

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21
Q

Indications for knee arthocentesis

A
  • Rule out septic arthritis
  • Differentiate between gout and pseudogout
  • Differentiate between inflammatory and noninflammatory effusions and hemarthroses
  • To drain large effusions, hemarthroses
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22
Q

Knee arthrocentesis

- procedural steps

A
  • patient supine, slight flex to knee
  • ID landmark, prep skin
  • place sterile drape
  • 18 gauge needle
  • super 1/3 of patella (medial or lateral), direct towards intercondylar notch
  • don’t contact bone with needle
  • pull back on plunger as insert needle
  • remove as much fluid as possible
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23
Q

NG tube insertion

- length of tube

A
  • ear to umbilicus
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24
Q

NG tube insertion

- confirm in correct place

A
  • Inject air and listen over stomach for bubbling

- CXR

25
Q

NG tube

- types of tube

A
  • straight suction: bigger but more likely to get clogged

- sump suction: less likely to get sucked against stomach wall and get plugged, smaller lumen so less suction ability

26
Q

Chest tube sizes

A
  • hemopneumothorax: 32-36 french
  • simple pneumo: 26-32 French
  • stable with isolated pneumonia: 12-20 french
27
Q

Insertion site for chest tube:

A
  • lateral thorax at anterior axillary line

- tube in 4th or 5th intercostal space (above the bone)

28
Q

Chest tube

- mateirals

A
  • lots of obvious stuff
  • 10 blade
  • surgical silk suture size 0
29
Q

Intubation

- Indications

A
  • CPR airway management

- Mechanical ventilation (resp failure, general anesthesia, coma)

30
Q

Intubation

- CI

A
  • massive maxillofacial trauma (relative)
  • fractured larynx
  • c-spine injury (relative)
31
Q

Anesthesia

  • Esters
  • Amides
  • which MC for allergic rxn
A
  • Amide: lidocaine, bupivocaine, mepivicaine
  • Ester: procaine, marcaine, cocaine

-ester more common to cause allergic reactions

32
Q

How to calculate dose of anesthesia medication in mg (formula)

A

volume (mL) * % concentration * 10

= dose(mg)

33
Q

Systemic toxicity reaction from anesthetic medication symptoms

A 
tongue numbness
lightheadedness
visual disturbances
muscular twitching
unconsciousness
seizures
34
Q

when is epinephrine CI?

A

digital blocks

35
Q

Diamond technique for local anesthetic admin

A
  • Visualize a diamond surround area to be anesthetized
  • Inject 2 small wheals at apex of the diamond
  • Next, block the 4 sides of the diamond through those wheals
36
Q

Digital block technique

A
  • Numb skin with lidocaine (faster onset)/bupivacaine (longer duration)
  • Introduce 25-guage needle at base of finger just below the web space and to the side of the base of the proximal phalanx
  • Advance needle until it nearly reaches other side of finger and inject 2-3mL of lidocaine as you withdraw. Redirect before fully withdrawing and inject another 1mL on dorsal part of finger
  • Remove needle and repeat procedure on the other side
37
Q

Three types of wound healing

A
  • First intention: wound is closed be routing primary suturing, stapling or gluing. Epithelialization occurs in 24-48 hours
  • Secondary intention: wound not closed by suturing, stapling or gluing but closes by spontaneous contraction and epithelialization at rate of 1mm/day. Most often used for wounds that are infected and packed open
  • Third intention (aka: delayed primary closure): wound left open for a time and then sutured at later date. Often used with grossly contaminated wounds
38
Q

Absorbable sutures

A
  • ____gut
  • Vicryl
  • others
39
Q

Nonabsorbable sutures

A
  • Gore-tex
  • Nylon/ethilon
  • polyester
  • polypropylene (polene)
  • silk
  • stainless steel
40
Q

Suture size for diff body locations

A
  • Face: 5-0 or 6-0 nylon or polypropylene when appearance important
  • Scalp: 3-0 nylon or polypropylene
  • Trunk/extremities: 4-0 or 5-0 nylon or polypropylene
  • Use 3-0 and 4-0 absorbable sutures such as Dexon or Vicryl to approximate deep tissues
41
Q

Types of suture pattern

A
  • simple interrupted
  • continuous running
  • vertical interrupted mattress (far far near near
  • horizontal interrupted mattress: calloused skin like palms and soles
  • Subarticular closure:
42
Q

Suture removal

A
  • don’t pull dirty suture through skin
  • continuous: cut and pull each part out separately
  • cut suture close to skin
  • thin scissors or 11 blade
43
Q

Punch biopsy

- Indications

A
  • Diagnostic tool for lesions/dermatoses that extend into deeper dermis
  • Removal of small/medium-sized lesions (ex: compound/dermal nevi)
44
Q

Punch biopsy

- how stretch skin

A
  • perpendicular to tension lines
45
Q

Punch biopsy

- how to deal with incision

A

<4 mm: can leave open to heal via secondary intention
>4mm: interrupted sutures on either side of defect
- 4.0 trunk/extremity
- 5.0 on face

46
Q

Punch biopsy

- when remove sutures

A
  • 7-10 for face

- 14 for trunk/extremities

47
Q

Shave biopsy

- indications

A
  • Dermatomes
  • Seborrheic keratosis/skin tags
  • Nevi (when melanoma not concern)
  • Suspected squamous/basal cell carcinoma
  • Controlled deep dermal shave biopsy appropriate for lesion considered for melanoma if adequate depth obtained
48
Q

Shave biopsy

- angel for superficial and saucerization

A
  • superficial: 10

- saucerization: 45

49
Q

Shave biopsy

- how to treat lesion

A
  • aluminum chloride
  • electrodessication if still bleeding
  • sterile petroleum jelly with bandage on all sides
  • remove in 24 hours and wash with soap/water, keep applying petroleum jelly for 14 days or until healed
50
Q

Cryotherapy

- indication

A
  • Treatment of benign/precancerous lesions
  • Commonly treated lesions include actinic keratoses, viral warts (HPV/molluscum contagiosum), seborrheic keratoses, skin tags
51
Q

Cyrotherapy

- technique

A
  • tip 1-1.5 cm from lesion
  • spray until 2 mm rim of frost appears
  • continue spraying 5-30 seconds depending on lesion
52
Q

Cyrotherapy freeze times

  • AK
  • SK
  • wart
  • Skin tag
A
  • AK: 5-20 seconds
  • SK: 5-10 seconds
  • wart: 10
  • skin tag: 5
53
Q

IV - types of catheter

A
  • short/large bore: rapid resuscitation

- small: admin of fluids, meds, abx. Less likely to obstruct blood flow or cause phlebitis

54
Q

US probes

A
  • curved: abd and OB
  • linear: soft tissue, small parts
  • Phased array: FAST exam and cardiac, small footprint enlarged
55
Q

US

- colors

A
  • Black: fluid (hemorrhage, blood, ascites, urine, bile)
  • Gray: solid (liver parenchyma, renal cortex, blood clot)
  • White: dense solid (diaphragm, renal capsule, blood vessel walls, fat)
56
Q

FAST exam

- RUQ

A
  • Morrison pouch
  • 8th and 11th rib on mid-axillary line
  • black between kidney and liver = intraperitoneal fluid
  • fluid between outline of kidney and inside = renal hematoma, cysts, etc.
57
Q

FAST exam

- cardiac

A
  • pericardial effusion
58
Q

FAST exam

- LUQ

A
  • splenorenal
  • 8th and 11th rib on mid or posterior axillary line, aim more posterior than RUQ
  • blood around spleen
59
Q

FAST Exam

- pelvic

A
  • bladder
  • free fluid
  • Pouch of Douglas in females: collects blood between uterus and rectum

Capstone (3 decks)

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