Common OSCE procedures Flashcards
How should a question on LP technique be approached?
Consent
Analgesia/Anxiolysis
- Consider angel cream/emla over the skin prior to local infiltration
- Infiltrate 3-5mls of 1% lignocaine in the skin and subcut tissue down to interspinous ligament
- Give IV 1mg of Midazolam with more titrated to effect, monitor for respiratory depression
Positioning
- Lateral decubitus, maximum tolerable flexion of hips with back against the edge of the bed, have the back as vertical as possible
- Shoulders and pelvis properly aligned
Technique
- Consider CT prior to LP if signs/neurology consistent with raised ICP
- Palpate the Iliac crests and palpate medially to the vertebra (approx L3-L4 level)
- Full sterile technique
- Use of introducer to help determine the space
- Use of stylet when inserting and withdrawing the needle
- 25g standard, 22g for opening pressures/pressure measurement
- Advance until pop felt going through the ligamentum flavum
Reducing LP Headache
- Pencil tipped (sprotte) needles aka atraumatic needles 25g
- Smaller gauge needles
- Replace stylet prior to removing the needle
- Insertion with bevel in cephalad-caudad orientation
Difficult Lumbar puncture
- Sit the patient upright on the edge of the bed, feet on a stool, leaning over a pillow (can’t measure CSF pressure)
- Ultrasound marking of the vertebral space
- Longer needle (120-150mm) if obese
- Anaesthetics
- CT/Flouroscopy guided
What are the indications, contraindications and complications of Lumbar puncture?
Indications
- Suspected CNS infection
- Suspected subarachnoid haemorrhage
- Diagnosis and monitoring of a range of haematological, neurological and malignant conditions
- Intrathecal injection of medication (spinal anaesthetic, chemo etc)
Contraindications
- Overlying skin infection
- Patient not consenting and competent
- Bleeding diathesis (Platelets <50, INR >1.5, LMWH/Heparin last 24hrs, coagulopathic, anticoagulants)
- Trauma to the lumbar vertebra
- Concerns about increased ICP and risk of herniation (new seizures, lateralising neurology, anisocoria etc)
- Significant haemodynamic or respiratory compromise
Complications
- Post LP headaches
- Transient back pain (limit number of attempts)
- Infection (sterile technique)
- Bleeding (correct coagulopathy)
- Brainstem herniation
- Epidermoid tumour (Use a stylet when inserting the needle)
- Failure of procedure
How should an OSCE of Suprapubic Catheter insertion be approached?
ICED PACKS
Indications
- Urinary retention and unable to catheterise via the urethra
- Urinary sampling unable or unideal to perform via the urethra (ie infants)
- Need for long term catheterization to reduce complications to urethra
Contraindications
Absolute
- Unable to locate the bladder
- Overlying skin infection
Relative
- Coagulopathy
- Insufficient urine in the bladder
- Distorted anatomy (previous surgery, irriadiation etc)
- Bowel anterior to bladder (ie bowel obstruction, altered anatomy etc)
Equipment/Drugs
- Needle, syringe
- Dilator, guidewire and sheath
- 14-16Fr IDC
- Lignocaine, IV analgesia
- Sterile field and equipment
Preparation/Steps
- Full sterile technique, chlorhex or iodine swabs
- Palpate 2 finger breadths above the pubic symphisis +/- locate with ultrasound
- Infiltrate 5mls 1% lignocaine in the skin down to the rectus abdominus
- Insert needle with syringe whilst aspirating, aiming 10-20 degrees towards the pelvis
- do not aspirate all urine (need some distension to pass catheter)
- Feed guidewire through needle then remove needle, use dilator to enlarge the tract
- Railroad the sheath over the wire into the bladder, remove dilator and wire
- Insert the catheter through the sheath, remove the pull away sheath without removing the catheter
- Inflate the balloon and attach to drainage bag
- Confirm placement/complications with ultrasound, contrast xray or CT
- Review +/- admission under Urology
Alternatives
- IDC
- Drain but don’t place SPC
Keep Going
- Admit Urology for formal tract formation
- Consider ultrasound/CT to confirm correct placement
Complications
- Surrounding structure perforation (bowel, rectum, vagina etc)
- Through and through bladder injury with extravasation (intra or extraperitoneal)
- Infection
- Inadevertent urethral catheterisation
- failure of procedure
- Haematuria, obstruction
Special Points
- Can use a CVC as a temporising measure if no formal SPC pack
Biers blocks OSCE approach?
ICED PACKS
Indication
- Distal extremity procedures needing anaesthesia (large lac repair, fracture reduction, joint relocation, burn debridement, abscess drainage, removal of foreign bodies
Contraindications
- Patient non-compliance/refusal
- Open fracture/crush injury
- Neurovascular compromise/PVD
- Morbid obesity/Lymphoedema
- LA allergy
- Severe HTN (>200 systolic)
- Reynauds/Beurgers/Sickle cell
- Methaeglobinaemia (prilocaine)
Equipment/Drugs
- Pneumatic cuff
- Lignocaine 3mg/kg or Prilocaine 3mg/kg diluted to 0.5% solution
- Saline for diluent
- Syringe for injection
- Cannula in distal aspect of limb with 2nd cannula on another limb
Preparation/Steps
- Consent
- Have equipment for limb procedure (plaster etc)
- Check cuff works and won’t fail
- Velband underneath cuff
- Resus, sats/ECG monitoring, 2 docs + nurse, 1 airway trained
Alternatives
- Sedation, haematoma block, nerve block
Keep Going (Post procedure)
- After 20mins cuff(s) can be let down, aim for 30mins
- Between 20-30mins consider letting the cuff down in stages to reduce sudden bolus lignocaine
- Do not keep up longer than 45mins (risk of compartment syndrome and ischaemia)
Complications
- Pain, bruising
- Methhaemglobinaemia
- LAST
- Neruovascular injury
Special points
- Access to 20% intralipid/Methylene blue
- Cannula needs to be at least 10cm distal to cuff (prevent injection under the cuff)
Transcutaneous Pacing OSCE approach? Trouble shooting defibrillator approach?
ICED PACKS
Indications: Haemodynamically unstable bradycardia (MBII/III, sick sinus syndrome) or overdrive pacing (ie TdP from long QT)
Contraindications: Severe hypothermia, toxic overdose (ie digoxin), severe agitation, palliative, asymptomatic
Equipment/Drugs: 12 lead ECG, pacing pads, wires, box
Analgesia/sedation (ketamine, midazolam, fentanyl etc)
Preparation: Consent
- Defibrillator/pacing machine attached
- +ve R) sternum and -ve L) apical
- or +ve L) lateral spine beneath scapula and -ve between xiphoid and just under L) nipple line (V3)
- Pacer mode, demand setting, synchronised
- 60-70 bpm, start 70mA (milliamps)
- When electrical and mechanical capture set mA 5-10 above threshold
Alternatives
- Isoprenaline, adrenaline
- Transvenous pacing
Complications: Failure to capture, failure to pace, burns, pain, unstable rhythm (VF, TdP)
Keep Going
- Admit cardiology
- Transvenous pacing, PPM insertion
- +/- OCU
Special Points: Always check mechanical capture (femoral pulse, bedside echo etc)
Trouble Shooting
Machine
- Defibrillator actually charged?
- Check machine power, battery and plugged in
- pads applied properly + plugged in
- Pads on the machine setting
- Synchronised mode may not work if chaotic rhythm (VT, PVT, WPW with AF) and need to use
- Correct mode
Unsynced
Patient
- High impedence (ie fat), consider pushing pads down (controversial)
- Wrong joules (higher dose)
- Change pad positions (AP vs lateral)
Operator
- Re-check technique, hold button down til defibrillates
When discussing options for treatment, how should this be approached?
Good mnemonic for any OSCE procedure?
Comparing Options
Efficacy
- Likelihood of success and acceptable outcome
- Recurrence of condition (ie pneumothorax)
- The Gold Standard
Safety
- Invasive procedures out of hours
- Ability to deal with complications if they occur
- Appropriate level of training
- Medicolegal etc
- Radiation risks, need for fasting etc
Availability
- Timing, staff, need for transfer, specialists on site etc
Acceptability
- Does the patient/family consent, will they tolerate the potential risks vs benefits, will they tolerate the side effects or pain
ICED PACKS
Indications
Contraindications
Equipment
Drugs
Preparation (Steps)
Alternatives
Complications
Keep going (post procedure)
Special points
What is the OSCE approach to CVC insertion?
ICED PACKS
Indications
- Infusions (vasocative, irritant)
- Extracorporeal therapy (haemodialysis, apheresis, ECMO)
- Inadequate peripheral access (ie large bore access for MTP)
- Transvenous pacing
Contraindications
- Unco-operative patient
- Coagulopathy (plat <50, INR >1.5, APTT >50)
- Obstructed vein
- Overlying infection
- Unable to lie flat (internal jugular)
- Cervical trauma/collar (IJ)
Equipment/Drugs
- 10mls lignocaine 1% + syringe +/- IV sedation and analgesia (midazolam, fentanyl, ketamine etc)
- Ultrasound, sterile cover/gel
- Multi-lumen CVC, guidewire, dilator
- Suture/suture kit, scalpel
- 10mls sterile water, 10ml syringe
- Sterile drape/prep area and antiseptic (chlorhex etc)
- 25g needle and drawing up needle
- capless valves for each lumen
Preparation/Steps
- Consent (if non-emergent)
- Perform in resus bay with full monitoring, prep and drape
- Sterile gown, gloves, mask, hair net
- Identify vein with U/S
- Anaesthetise skin
- Insert needle/syringe, drawing back causing negative pressure until blood flashback into syringe
- confirm position with ABG, pressure transduction and/or manometry
- Remove syringe and insert guidewire to approx 15cm, then remove needle
- Confirm guidewire positiong with US
- nick skin with scalpel next to wire to help with dilation
- Railroad dilator until just through the skin/soft tissue, then remove
- Thread catheter over the wire, always hold or visualise guidewire
- Remove wire and lock catheter to prevent blood backflow
- Aspirate and flush all lumens
- Suture, place dressing
- Check guidewire is complete and undamaged
Alternatives
- Peripheral access (slower and higher risk infusions)
- IO access
- Change CVC site, PICC line
Complications
- Failure
- Bleeding, thrombosis
- infection (local, systemtic, CLABSI)
- Neurovascular injury
- Pneumo/haemothorax (IJ, SC)
- Air embolus
- Arrythmias
- Shearing/loss of guidewire
Keep Going
- CXR to confirm position and assess for complications (IJ/SCV)
- Document
Special points
- When inserting guidewire, check for PVCs/PAC’s as will show intracardiac
- Never force the wire
- On CXR tip should be just in line with Carina (approx RA)
- Ultrasound guidance reduces number of attempts and immediate complications
- If carotid artery puncture maintain 5-10minutes of pressure, assess for large haematoma formation
- Cannulation/dilation of carotid needs discussion with vascular team
- Loss of wire needs urgent discussion with IR and vascular
What is the OSCE approach to Scalpel Cricothyroidotomy?
ICED PACKS
Indications
- Inability to oxygenate or ventilate (CICO) by other means (BVM, ETT, LMA)
- Expected difficult or impending loss of airway (severe facial trauma, trismus, massive haemorrhage, obstructing lesions, congenital deformity, anaphylaxis etc)
- Age >10yo
Contraindications
- Laryngeal fracture
- Tracheal ruprute/transection
- <10yo, palliative
Equipment/Drugs
- PPE (gloves, gown, face shield)
- Scalpel 11-15, lubrication
- Bougie, size 6.0 ETT, BV<
- Ventilator, tubing, oxygen supply
- Large bore suction catheter
- 10ml Syringe
- Sutures, ETT tape or tie
- Hard collar
- 5mls lignocaine 1% with adrenaline (if time allows, but not if truly emergent)
Preparation/Steps
- Resuscitation area
- Supine, neck extended
- Stand lateral to patient, dominant hand towards the head
- Palpate thryoid prominence, move fingers inferiorly until depressione between thyroid/cricoid cartilage found (CTM)
- Stabilisie larynx with non-dominant hand thumb and middle finger (laryngeal handshake)
- Make 15mm transverse incision through the CTM, if unable to palpate then do 8cm vertical incision first and blunt dissect down with fingers until identified
- Insert finger and palpate tracheal rings for confirmation
- Insert bougie under palp of inger until hold up felt (approx 10-15cm)
- Rail lubricate ETT with twisting motion until cuff just inside trachea
- remove bougie, inflate cuff and confirm position with ETCO2
Alternatives
- BVM, LMA or ETT
- Needle cricothyroidotomy
- Tracheostomy
Complications
- Failure, false passage
- Bleeding and aspiration
- Neurovascular, oesophageal and laryngeal injury
- Perforation of posterior trachea
- Infection, coughing
Keep Going
- Secure with tape +/- suture and allocate assistant to hold ETT
- CXR to confirm position
- ENT/Anaesthetics/Surgery for consideration of formal tracheostomy or formal airway
- ICU for further care
- Sedation, paralysis, document
Special points
- Voice loudly and clearly to whole team that you are performing FONA
- Attempts at ventilating with LMA can still be done whilst performing the procedure
- Hard collar can help maintain neck position post procedure
- Early hold up of bougie can suggest false passage
- Ultrasound can be used to help identify CTM, time permitting
- Aim scalpel caudad to prevent damage to the vocal cords
What are the differences in technique between IJ, SC and femoral CVC’s for the OSCE?
IJ Positioning and insertion
- Supine on an incline
- Head down 15 degrees, slightly rotated away from the puncture site
- Insert between medial and lateral heads of SCM in the triangular gap approx 5cm above the clavicle
- Lateral to carotid pulsation, angle at 30 degrees to skin, aiming towards ipsilateral nipple (medial to lateral approach)
- Insertion R) height/10, L) height/10 + 4cm
- Low infection and complication rate, R) IJ usually the preferred
SCV positioning and insertion
- Supine position, trendelenburg, rolled up towel between the scapula, caudal traction on the ipsilateral upper limb to 5cm inferior to resting position
- Insert needle 2cm inferior to the clavicle midpoint
- R) height/10 -2cm, L) height/10 + 2cm
- Lowest infection rate, lowest success rate, highest complication rate, most comfortable
Femoral positioning and insertion
- Supine on incline with slight head elevation
- Leg extended, hip external rotation
- Artery lateral, vein medial
- Insert needle just inferior to the inguinal crease
- Insert catheter up to hub
- Highest rate of infection, lowest rate of complications
- Easier to pull back a CVC that is too deep, than force a CVC further that is too shallow
How should a radial arterial line OSCE be approached?
ICED PACKS
Indications
- Arterial pressure monitoring (unstable, failed NIBP, titrating vasopressors)
- Regular blood sampling
Contraindications
- Proximal traumatic injury
- Coagulopathy
- Overlying infection
- Deficient collateral circulation
- PVD/Raynauds (relative)
Equipment/Drugs
- Resus or monitored acute bay, 1x assistant
- 5mls 1% lignocaine, 25g needle and syringe 5mls
- Sterile drape and field
- Antisepsis (chlorhexidine)
- Ultrasound
- Arterial transducer, saline, pressure bag and tubing
- Arterial cannula +/- guidewire
- Sutures and dressing
-Rolled towel and tape
Preparation/Steps
- Supine, arm and wrist in extension
- Hand/wrist immobilised
- Palpate/US location of artery
- Prep and drape, local anaesthetic
- Insert needle 30-45 degrees, arterial flashback, lower angle and insert another 1cm
- Cannulate or seldinger with guidewire
- Confirm position with ABG and pulsatile blood flow
- Suture, arm board to hold wrist in extension
- Transducer at phlebostatic axis (atria, 4th ICS mid axillary line)
Alternatives
- Regular NIBP
- Regular peripheral blood draws
Complications
- Failure
- Pain, infection
- Thrombosis, distal ischaemia
- Nerve injury
- Arterial injury (dissection, transection, pseudoaneurysm
Keep going
- Calibrate by setting off to patient and open to air
- Press 0 on monitor, when zero on screen open to patient and transducer and off to air
- Document and perform regular limb neurovascular observations
Special points
- Never force catheter or guidewire
- Lignocaine reduces pain and also vasospasm
- Allens test may be performed, but evidence is weak and a positive does not mean no risk of ischaemic complications
What is the OSCE approach to LMA insertion?
ICED PACKS
Indications:
- Need for oxygenation and ventilation
- Rescue device for BVM and ETT
- Intraarrest airway device
- Pre-oxygenation for upper airway bleeding (compared to BVM, before ETT insertion)
Contraindications
- Patient not either deeply sedated or paralysed
- Presence of gag reflex
- Airway obstruction from FB
- Known oesophageal varices
- Oropharyngeal or proximal oesophageal disease (perforation)
Equipment/Drugs
- Same as for ETT intubation
Preparation/Steps
- Same as for intubation up until point of insertion
- Neck flexion but with atlanto-occipital extension
- Deflate cuff (if present) and apply water based lubrication
- Have assistant help open mouth initially, then perform jaw thrust to open pharynx
- Grasp by hard bite block, cuff aiming towards patients chin
- Slide tip along superior hard palate down oropharynx
- Cease pressure when definitive resistance met, bite block should be against patients incisors
Inflate cuff if present, tape the LMA in from maxilla to maxilla
- BVM/ventilator and assess capnography/chest
Alternatives
- ETT, BVM, Guedel or NPA
- Wake patient to spont breathe
Complications
- Failure of placement
- Failure of oxygenation/ventilation
- Laryngospasm
- Vomiting and aspiration
- Pain
- Airway or proximal oesophagus injury/bleeding
Keep going
- Ongoing sedation +/- paralysis
- Consider conversion to ETT when stabilised
- Documentation
- ICU or theatre
Special points
- If weight uncertain use larger LMA
- Superior to BVM in most aspects ie less aspiration, better oxygenation, easier to maintain seal, easier to teach
- Sedation +/- paralysis will be needed to tolerate an LMA ongoing
What is the OSCE approach to Intubation with an ETT?
ICED PACKS
Alternatives
- Don’t intubate
- LMA
- BVM
- FONA
- Airway adjuncts
- Oral vs nasal
- Direct vs VL vs bronchoscope
6Ps of intubation
Preparation
- Blade, ETT, suction, 02 delivery, capnography, telemetry, BP and sats, secured IV line, perform in resus
- All RSI meds and vasopressors
- Assess for difficult airway
Preoxygenation
- NRB vs NIV vs BVM
- Ideally 3minutes of 100% 02
Pre-Treatment
- IV fluids, vasopressors
- Consider fentanyl or lignocaine to reduce sympathetic drive from laryngoscopy
- Atropine in neonates
Paralysis with induction
- Ketamine or props
- Sux or Roc
Placement
- Passage of ETT
- VL, bougie, stylet
- Inflate cuff, listen for leak
- Confirm with auscultation, capnography, misting and CXR
Post intubation
- Ongoing sedation (props and fent, midaz and morph)
- Paralysis if needed
- Ventilator settings
- Check for complications
What are the differences between direct and indirect (video) laryngoscopy? Mac and Hyperangulated blades?
Video Advantages
- Can look around corners
- Others can see the image (teaching, confirmation, remote area support)
- Recording (teaching, QA and QI)
- Images are enlarged
- Reduced cervical spine motion
- Reduced lifting forces on base of tongue
How is an Intubating LMA (ILMA) different to other LMA?s
- Fastrach ILMA is the main type
- Can be used as an introduced to then pass a normal or trademarked ETT through the ILMA
Procedure
- Insert as per normal LMA, although has a metal handle
- Confirm adequate ventilation/oxygenation, cuff up
- Take ETT and generously lubricate, largest useable size is 8.0mm
- 15cm is the end of the ILMA, advance to desired depth
- Getting stuck at 17cm suggests vallecular impaction
- No need to take out ILMA straight away, safe to stay in for extended periods
- To remove deflate the cuff, remove the ETT connector and push on the ETT to maintain in position
- Slowly remove the LMA with gentle swinging in a caudal direction
- Use the stabilising rod to keep the ETT from being pulled out
- Once ILMA out replace the ETT connector and check depth
- Replace on ventilator and check position
Special points
- Rotating the ETT 180 degrees (curve opposite to normal) can prevent the tip of the ETT catching and becoming impacted on the vallecula
How should an awake oral/nasal intubation OSCE be approached?
ICED PACKS
Indications
- Impending loss of airway (croup, epiglottis, airway burns, anaphylaxis etc)
- Severe airway, breathing or metabolic compromise from induction drugs
- High risk of difficult airway
- Compliant patient at low risk of vomiting
Contraindications
- Same as for asleep intubation
- assessment suggests unlikely to be difficult airway (inhumane to perform)
Equipment/Drugs
- 10+ mls Lignocaine 2% or Cophenylcaine
- Light sedation (low dose ketamine)
- Direct/video laryngoscope or fibre optic bronchoscope
-
Preparation/Steps
- Resus area, full team, ideally anaesthetics and ICU/ENT
- Topicalise mouth, oropharynx and vocal cords
- Slow and careful insertion of blade or scope to visualise the airway and determine difficulty
- This initial look may demonstrate barriers to nasal/oral intubation that mandate FONA
- OR it may demonstrate an good airway amenable to RSI
- blade/scope may then be withdrawn to plan for next step, or if excellent conditions on initial look may proceed with awake intubation at this time
Alternatives
- RSI/DSI
- Cricothyroidotomy/ostomy
- Tracheostomy
- No definitive airway
Complications
Keep going
Special points
- Injecting 5-10mls lignocaine through the CTM will provide topicalisation through coughing
C-spine Immobilisation (soft collar, hard collar, philadelphia collar and rigid spinal board)
What is the OSCE approach to Intraosseous access?
ICED PACKS
Indications
- See picture
Contraindications
- See picture
- Previous IO attempt in same bone
Equipment/Drugs
- See picture
Preparation/Procedure
- See picture
Alternatives
- Peripheral access
- Central access
- PICC
- IM/ET/NG/SC drugs
Complications
- See picture
Keep Going
- Document completion
- Monitor for extravasation and compartment syndrome
- Can leave in situ for 24hrs
- Remove by attaching 10ml luer lock syringe, traction and twist counterclockwise
Special points
- Marrow can be used for BSL, cultures and cross match
- Most accurate determinant of correct size is assessment of depth markings post insertion
- Gravity not enough, needs pressure bag or pump set
- Abduction of arm after humeral placement will dislodge IO, internal rotation of should prior can prevent this (thumb to floor)
- Avoid legs in pregnant, pelvic or abdo trauma
- Can’t test WCC, K+, Na+, ALT/AST, ionised Ca+, pCO2 or platelets
Ketamine sedation procedural approach?
ICED PACKS
Indications
- Short painful procedures especially if requiring immobilisation
- Behavioural control
Contraindications
- True allergy
- Infants < 12months
- Known or predicted difficult airway
- Cardiorespiratory compromise
- intercurrent URTI
- Oral/pharyngeal procedures
- HR sensitive cardiac disorders (MS, IHD, WPW etc)
- Bowel obsruction
- Porphyria, thyroid, psychosis
Equipment/Drugs
- 1mg/kg IV or 4mg/kg IM of IDEAL bodyweight
- 0.5mg/kg IV or 2mg/kg IM top up doses
Preparation/Proceed
- Informed consent
- Perform proper airway and anaesthetic assessment prior to ensure procedure is safe
- 3 well trained staff (airway, procedure and monitoring)
- Resus area, cardioresp monitoring
- Resuscitation and RSI equipment
- Capnography, non-rebreather 02
- Soothing and distraction techniques to reduce risk of emergence
Alternatives
- Nitrous, propofol etc
- Regional anaesthesia
- Procedure under GA
- Don’t do procedure
Complications
- Laryngospasma
- Airway obstruction
- Apnoea
- Vomiting
- Emergence phenomenon
- twitching, vocalisations
- hypersalivation
- Tachycardia/hypertension
Keep going
- Monitor in recovery area/SSU
- Return to neurological base
- Ideally eating/drinking
- Don’t discharge overnight
Special points
- IV doses should be given over 1-2 minutes to reduce risk of apnoea
Ankle and Knee arthrocentesis approaches
ICED PACKS
Indications
- Diagnosis of joint swelling (septic, crystal, blood, inflammatory)
- Relief of pain from haemarthrosis (usually specialist)
- Instillation of medications (usually specialist)
- Saline loading test (specialist)
Contraindications
- Overlying cellulitis
- Bleeding diathesis
- Acute fracture
- Patient refusal or uncooperative
- Prosthetic joint (relative, usually specialist)
Equipment/Drugs
- Chlorehexidine and ETOH
- Sterile dressing pack and drape
- 1% LA with 5ml syringe and 25g needle
- 18g needle with 20-50mls syringe
- U/S, sterile cover and gel
- Sterile gown, gloves, eye wear
- Sterile specimen containers and FBE tube
Preparation/Proceed
- Explain procedure and gain consent
- Pillow under knee and slightly flexed to 15 degrees, comfort
- Clean, prep and drap
- Inject LA 1cm medial to the anteromedal patellar edge at the midpoint of the patella
- Take 18g needle attach to syringe, insert at same site and direct between the posterior surface of the patella and intercondylar femoral notch
- Keeping the needle parrallel to the bed limits injury
- Apply slight negative pressure as advancing needle to get flashback
- If needing to change syringe, hold the hub of the needle with a haemostat
Alternatives
- Done in theatre
- Empiric treatment
Complications
- Failure
- Introduction of infection
- Bleeding
- Pain
- Allergy to local anaesthetic
- Damage to structures
Keep Going
- Put fluid into 3x containers for cytology, microbiology and biochem
- Monitor joint afterwards, if increasing pain can suggest haemorhage
- Dont walk for an hour to post
- Place pressure over the area and then a good absorbent dressing
Specialist points
- Ensure that quadriceps tendon is relaxed (makes joint space larger)
- “milk” the effusion by applying pressure in the suprapatellar region
- If using iodine do not allow it to go into the joint
- Do not inject lignocaine into joint if wanting to culture (bactericidal)
Pelvic Binder and leg Splint application and trouble shooting
Indication
- Blunt trauma with suspected pelvic fracture
+
Hypotension or cardiac arrest
Contraindications
- None
Equipment/drugs
- SAM sling or T-pod splint or a large sheet
- Consider analgesia
- Consent (simple, low risk
Prep/Procedure
- Supine
- Identify greater trochanters
- T-ppd needs to be cut so both sides are approx 15cm from eachother
- Counter traction helps prvent rolling the patient
- Place a sheet in figure of 8 around the ankles, secure with clamps
- Keep legs internally rotated, ideally slight flexion of knees with towel (cant do if also has femur splint)
- Adequate tension is 2 fingers just fit between the device and leg
Alternatives
- Pelvic sheeting
Complications
- Pain
- Failure
- Injury
- Pressure sores
Hip, Knee and ankle dislocation reduction options
General
- Essentially always need procedural sedation, propofol ideal due to muscle relaxation
- Post reduction xrays
- Discussion with ortho
Captain Morgan technique
- Anchor hips/pelvis to stretcher
- Sedate
- Place knee your knee under their knee, slow raise leg using your foot
Whistler technique
- Squat down, place own arm under affected leg and onto opposite bent knee, slow rise to standing, using opposite knee as fulcrum
Knee (usually anterior)
- usually reduces with prolonged longitudinal traction
- 50% spontaneously reduce
- Consider CT angio vs ultrasound and ortho/vasc consults
- ABI and neurovasc monitoring
- Splint in 20 degrees flexion
Patella (usually lateral)
- Supine and knee flexed
- Two thumbs on lateral patella, pushing medially while extending knee
Ankle
- Ideally ortho to reduce
- ED reduce if skin tenting or neurovasc compromise
- longitudinal traction and rotation in opposite direction of dislocation
- POP, neurovasc monitoring, admit
CTG application and interpretation
Early decelerations
- Decelerations are an abrupt drop in HR >15bpm for >15secs
- Early are caused by cranial compression with vagal response
- Consider physiological
- Prolonged deceleration >3mins is considered abnormal
Variable decelerations
- Usually from cord compression
- Non-reassuring
- Usually first treated with repositioning of the mother
- Accelarations pre/post (shoulders) are a sign the foetus is not yet hypoxic and is adapting
Late Decelerations
- Suggestive of insufficient blood flow to the placenta/baby
- Causes include maternal hypotension, pre-eclampsia, uterine hyperstimulation
- It is a high risk finding and usually warrants emergent delivery
Accelerations
- An abrupt increase in HR >15bpm for >15secs
- Sign of healthy foetus and reassuring
- Absence of accelerations in otherwise normal CTG is of unclear significance
Variability
- Reassuring, non-reassuring or grossly abnormal
- Reassuring = 5-25bpm
- Non-reassuring= <5bpm or >25bpm for prolonged period (25-30mins)
- Abnormal = <5 for >50mins or >25 for >30mins, sinusoidal pattern
- Normal HR 120-160, cause of bradycardia and tachycardia are similar to that of infant
- Severe bradycardia is <80 for >3mins, suggests severe hypoxia
Reduced Variability
- Needs to be interpreted in context
- Maternal/foetal opioid exposure
- Foetal sleeping (most common cause, no longer than 40mins)
- Congenital heart defect/prematurity
- Foetal acidosis (if late Decels also)
- Foetal tachycardia of any cause
Sinusoidal pattern
- A rare but highly concerning finding, associated with high morbidity and mortality
- No beat-beat variability, stable HR, 2-5 cycles per minute
- Smooth regular wave-like pattern
- Caused by severe foetal hypoxia, severe anaemia or foeto-maternal haemorrhage
Spirometry and PEFR
Obstructive pattern
- FEV1 significantly reduced but FVC tends to be near normal, hence FEV1/FVC ratio <0.7
- GOLD criteria for COPD
- Check if bronchodilator reversibility
- If reversible (>12% FEV1 increase and >200mls FVC), suggests asthma over COPD
Restrictive
- Reduction in both FEV1 and FVC but proportional
- Non-pulmonary (obesity, pregnancy, neuromuscular disease)
- Pulmonary (fibrosis, oedema, lobectomy, tumours)
Initiating and trouble shooting NIV
ICED PACKS
Indications
- T1RF (usually CPAP)
- T2RF (BiPAP)
- Specific conditions (Asthma, COPD, APO, NMD, Pneumonia, OSA, OHS, cystic fibrosis)
- Delayed sequence intubation
- Bridge to intubation
Contraindications
- Cardiac/Resp arrest
- Untreated pneumothorax
- Not protecting airway (obtunded, excessive secretions)
- Haemodynamic instability
- Certain surgeryies (upper GI, maxillofacial, base of skull fracture or surgery, severe facial trauma)
- Staff inexperience, patient refusal
- Intractable vomiting
Equipment/Drugs
- Ventilator
- Mask
- Sedatives if needed
- 02 supply
Alternatives
- NP, HFNP, NRBM
- Intubation
- Spontaneous breathing
Complications
- Pneumothorax
- Intolerance
- Pressure injuries (face, nasal bridge)
- Ocular abrasions
- Anxiety/agitation
- Aspiration, air swallowing with gastric distension
- Impaired communication
- Raised ICP and IOP
- Hypotension
Special points
- Very strong evidence for moderate hypercapnoea and hypoxia
- Failure more likely in obtunded, very elderly and severe hypercarbia
- No evidence for ARDS and not recommended
Extubation in the ED
Indications:
- Underlying reason for intubation has resolved
- Patients requiring palliation
Contraindications:
- High ASA score
- Difficult predicted or actual airway (Cormack-Lehane grade, Mallampati, thyromental distance etc)
- Complications or multiple attempts required (allow airway oedema to improve)
- Underlying reason for intubation not resolved
- Haemodynamically unstable
- Ventilation and Oxygenating well
- Inadequate mental status to protect airway
Equipment/Drugs:
- Ventilator, BVM
- 10ml syringe, ETT
- Perform in resus
- Airway trained Dr and RN
- 7 P’s for intubation (in case need to re-intubate)
Procedure:
- Awakening trial off sedatives to assess mental capacity (follows commands, GCS 10T at least, can raise arms above head for 15seconds, raise head off bed, FVC >20ml/kg)
- Breathing trial for 30mins sitting at 45 degrees (IPAP 5-10, PEEP 5, Fi02 0.4 or less, aim sats >94)
- Failure significant by significant tachypnoea, Bradypnoea, agitation, respiratory distress, hypotension, arrhythmia or sats <88%
- If passed check for leak with cuff down (no leak concerning for oedema)
- Consider low dose fentnayl infusion to reduce pain and discomfort
- If passed above then Fi02 to 100%, difficult airway trolley and NIV nearby
- Insert bite block and suction ETT
- Apply positive pressure, as patient exhales deflate cuff and pull tube
- Observe in resus for 1hr post, NIV or NRB for 02 support
Alternatives:
- Extubation in ICU
- Transition to trache in ICU
Complications:
- Need for re-intubation
- Laryngeal/vocal cord injury
- Aspiration
Keep Going:
- Close monitoring in resus area over the next hour to ensure not worsening
Specialist Points:
- Consider NIV bridging post
Resuscitative hysterotomy
Emergent Delivery in the ED and shoulder dystocia techniques
Birth Equipment/Drugs
- Sterile gloves
- Sterile towels
- scissors
- Umbilical cord clamps
- Sterile 4x4 gauze
- sutures and suturing equipment
- Oxytocin 10 units IM
Neonatal equipment/Drugs
- Neopuff/neonatal BVM and mask
- Resuscitaire/neonatal rewarmer
- UVC
Steps
- Call for help (obs, paeds, anos)
- Resus area, 2x teams
- Large bore access x2, ABC’s
- Clean and drape perineum
- Place 1 hand on head to minimize uncontrolled movements, other hand to support perineum
- Reassure, only push during contractions, when head presents stop pushing during contractions
- Gentle downwards traction to deliver the anterior shoulder
- Gentle upwards traction to deliver the posterior shoulder
- DONT drop the baby
- Once baby delivered confirm if second pregnancy present
- Clamp and cut the cord 3cm from abdomen
- Stimulate, APGAR’s, neoresus if needed
- IM or IV oxytocin, fundal massage
PPH Drugs/Management
- 10U IM syntocinon
- Fundal Massage
- Evaluate 4T’s (Tone, trauma, tissue and thrombin)
- G+H, organise MTP, assess and correct bleeding/trauma parameters
Shoulder Dystocia (HELPER)
H- Get help
E- evaluate for episiotomy
L- Legs flexed (McRobers maneuvre, knees to nipples)
P- Suprapubic pressure, place bladder catheter
E- Enter vagina (woods corkscrew, reubens maneuvre etc)
R- Remove posterior arm
Cord Prolapse
- When head presents sweep fingers over the neck to find cord
- Support the head
- Attempt to slide cord over head
- Fill the bladder
- Worst comes to worst clamp and cut the cord and deliver baby ASAP
Breech delivery
- Confirm with U/S or Hx
- HELP!!!
- Neoresus highly likely
- See pic
Special points
- Don’t forget a second team to resuscitate the baby!
- Dont forget to look for a second baby!!!!
Priapism Approach
Indications
- Persistent erection >4hrs but <72hrs
- Usually caused by drugs of abuse, envenomation, leukaemia and sickle cell disease
Contraindications/Consent
- High flow (non-ischaemic)
- Groin trauma
- Acute spinal injury
- Priapism >72hrs (surgery)
Equipment/Drugs
- Sterile glown/goves/eyes cover
- Light sedation (fent/ket)
- Chlorhex solution
- 3-4mls lignocaine, 25g needle, 5ml syringe
- 2 or more 10-20ml syringes
- 2x 19g butterfly needles
- 1x 18g needle with extension tubing
- 4x 10ml N. saline
- VBG syringe
- Phenylephrine diluted to 100mcg/ml or adrenaline 10mcg/ml
Procedure/Prep
- consent (simple, low risk)
- Monitored bed with telemetry (vasopressors used)
- Sterilise, gown and drape
- Inject lignocaine for penile block
- May need light sedation
- Insert butterfly syringe anterolateral, 45 degrees distal and deep
- Aspirate blood, send for VBG
- Inject 100-200mcg phenylephrine (max 1000mcg)
- Alternate aspiration, injection and irrigation
- May need to change to larger needle and syringe
Alternatives
- Theatre
- Oral (pseudoephrine 120mg, midodrine 10mg) and IV meds
- Exercise, urinate
Complications
- AVM
- Haemorrhage/anaemia
- Failure
- Pain
- Introduction of infection
- Neurovascular injury
- Erectile dysfunction
Keep Going
- Clean and dress (elastic bandage
- cardiac monitoring for 1hr
- General monitoring for another 2hrs, confirm no recurrence and passed urine
- IV fluids and analgesia
- Admit Uro +/- theatre
- Consider oral pseudoephedrine 120mg for 3 days
Special points
- Low flow is a **compartment syndrome and Urological emergency **
- Ischaemic VBG = P02 <30, co2 >60 and pH <7.25
- May remove large quantities of blood before detumescence, consider G+H and need for transfusion
- Milking the shaft/cavernosum can be needed to break up the clot, along with repeated irrigation
Slit Lamp
Remember that flouroscein strips themeselves can cause small abrasions
