Clinical Skills Mishmash Flashcards
Which is more medial, IJ or carotid?
IJ more medial than carotid
when placing subclavian CVC, what landmarks do you use?
Insert needle where medial and middle thirds of clavicle meet
Seldinger technique overview
- 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
MC complication of CVC
pneumothorax
also vascular issues, infection, dysrhythmia, nerve injury, other thorax issues, etc.
CVC
- pro and con of IJ
- Advantages: bleeding easily recognized, rarely malpositioned, less pneumothorax risk, ease of US guidance
- Disadvantages: patient discomfort, risk of carotid artery puncture
CVC
- pro and con of subclavian
- 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
CVC
- pro and con of femoral vein
- 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
LP indications
- 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
LP Technique
- 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
LP complications
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)
Equipment and materials for MSK injections
- betadine/alcohol
- 22 gauge, 1 1/2 inch needle
- corticosteroid
Indications for knee joint injection
- OA
- other noninfectious inflammatory issues
Indications for subacromial joint injections
- rotator cuff syndrome
- shoulder impingement
- subacromial bursitis
MSK injection: appropriate dose of lidocaine and steroid
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
Corticosteroid injections
- pros
- inexpensive,
- easy to administer,
- often provide quick and long-lasting relief of pain dt arthritis, tendonitis, bursitis, etc.
Corticosteroid injections
- frequency
- some disagreement.
- Best rule is no more than every 4 months, max duration 3 years.
Corticosteroid injections
- sterile technique
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)
Corticosteroid injections
- systemic effects
- 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
Corticosteroid injections
- MC used
kenalog
depo-medrol
Corticosteroid injections
- which preparation to use
- suspension: should be cloudy or have a chalky end
- NOT solution which is clear as water
Indications for knee arthocentesis
- Rule out septic arthritis
- Differentiate between gout and pseudogout
- Differentiate between inflammatory and noninflammatory effusions and hemarthroses
- To drain large effusions, hemarthroses
Knee arthrocentesis
- procedural steps
- 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
NG tube insertion
- length of tube
- ear to umbilicus
NG tube insertion
- confirm in correct place
- Inject air and listen over stomach for bubbling
- CXR
NG tube
- types of tube
- 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
Chest tube sizes
- hemopneumothorax: 32-36 french
- simple pneumo: 26-32 French
- stable with isolated pneumonia: 12-20 french
Insertion site for chest tube:
- lateral thorax at anterior axillary line
- tube in 4th or 5th intercostal space (above the bone)
Chest tube
- mateirals
- lots of obvious stuff
- 10 blade
- surgical silk suture size 0
Intubation
- Indications
- CPR airway management
- Mechanical ventilation (resp failure, general anesthesia, coma)
Intubation
- CI
- massive maxillofacial trauma (relative)
- fractured larynx
- c-spine injury (relative)
Anesthesia
- Esters
- Amides
- which MC for allergic rxn
- Amide: lidocaine, bupivocaine, mepivicaine
- Ester: procaine, marcaine, cocaine
-ester more common to cause allergic reactions
How to calculate dose of anesthesia medication in mg (formula)
volume (mL) * % concentration * 10
= dose(mg)
Systemic toxicity reaction from anesthetic medication symptoms
tongue numbness lightheadedness visual disturbances muscular twitching unconsciousness seizures
when is epinephrine CI?
digital blocks
Diamond technique for local anesthetic admin
- 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
Digital block technique
- 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
Three types of wound healing
- 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
Absorbable sutures
- ____gut
- Vicryl
- others
Nonabsorbable sutures
- Gore-tex
- Nylon/ethilon
- polyester
- polypropylene (polene)
- silk
- stainless steel
Suture size for diff body locations
- 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
Types of suture pattern
- simple interrupted
- continuous running
- vertical interrupted mattress (far far near near
- horizontal interrupted mattress: calloused skin like palms and soles
- Subarticular closure:
Suture removal
- 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
Punch biopsy
- Indications
- Diagnostic tool for lesions/dermatoses that extend into deeper dermis
- Removal of small/medium-sized lesions (ex: compound/dermal nevi)
Punch biopsy
- how stretch skin
- perpendicular to tension lines
Punch biopsy
- how to deal with incision
<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
Punch biopsy
- when remove sutures
- 7-10 for face
- 14 for trunk/extremities
Shave biopsy
- indications
- 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
Shave biopsy
- angel for superficial and saucerization
- superficial: 10
- saucerization: 45
Shave biopsy
- how to treat lesion
- 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
Cryotherapy
- indication
- Treatment of benign/precancerous lesions
- Commonly treated lesions include actinic keratoses, viral warts (HPV/molluscum contagiosum), seborrheic keratoses, skin tags
Cyrotherapy
- technique
- tip 1-1.5 cm from lesion
- spray until 2 mm rim of frost appears
- continue spraying 5-30 seconds depending on lesion
Cyrotherapy freeze times
- AK
- SK
- wart
- Skin tag
- AK: 5-20 seconds
- SK: 5-10 seconds
- wart: 10
- skin tag: 5
IV - types of catheter
- short/large bore: rapid resuscitation
- small: admin of fluids, meds, abx. Less likely to obstruct blood flow or cause phlebitis
US probes
- curved: abd and OB
- linear: soft tissue, small parts
- Phased array: FAST exam and cardiac, small footprint enlarged
US
- colors
- 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)
FAST exam
- RUQ
- 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.
FAST exam
- cardiac
- pericardial effusion
FAST exam
- LUQ
- splenorenal
- 8th and 11th rib on mid or posterior axillary line, aim more posterior than RUQ
- blood around spleen
FAST Exam
- pelvic
- bladder
- free fluid
- Pouch of Douglas in females: collects blood between uterus and rectum
