Critical care

Question 1

IJV line insertion steps

Answer 1

• Consent
• Head down, facing away
• Aseptic technique
• Local anaesthetic to skin, prep and drape
• USS to identify IJV
• Lower 1/3 of neck, between heads of SCM. Insert at 30 degrees and angle towards sternal notch
• Continually aspirate
• Seldinger technique, advance guidewire
• Confirm guidewire in position with USS
• Stab incision, advance dilator
• Insert line over guide wire
• Remove guidewire, secure line, flush ports, sterile dressing

Question 2

Which position to remove central line and why?

Answer 2

• Head down facing away from side of line
• Prevent air embolus
• Compression for 5 minutes, send tip for MCS

Question 3

Anatomical course of IJV

Answer 3

• Formed from sigmoid and inferior petrosal sinus
• Exits skull through jugular foramen
• Descends in carotid sheath
• Receives tributaries from pharyngeal veins, lingual vein, superior and middle thyroid veins
• Joins SCV to form brachiocephalic vein

Question 4

Indications for central venous access

Answer 4

• CVP monitoring
• Infusion of vaso-irritant drugs (TPN)
• Infusion of vasoactive drugs (inotropes)
• Inadequate peripheral access

Question 5

Talk through assessment of CXR

Answer 5

• Confirm patient details
• Quality of film: RIPE
• A: Trachea, carina, bronchi and hilar structures
• B: Lung fields, pleura
• C: Heart size, borders
• D: Diaphragm (Chiadati syndrome = presence of colon between liver and diaphragm. DDX free air), CPA
• E: Mediastinum, bones, soft tissues, lines, pacemakers

Question 6

Difference between simple and tension pneumothorax

Answer 6

• PTX = Air in the intrapleural space if pressure alveoli > intrapleural pressure. Equilibration of pressure and resolution if source is completely sealed. Primary (no underlying lung disease) or secondary.
• Tension PTX = Unsealed pleural defect acts as a one-way valve. Inspiration leads to pleural air leak which cannot equilibrate. Rising intrapleural pressure leads to displacement of mediastinal structures.

Question 7

Complications of central line

Answer 7

• Immediate: damage to pleura (pneumothorax), carotid artery (haemorrhage), air embolism, guidewire migration
• Early: displacement, blockage
• Late: sepsis, thrombosis

Question 8

Risk factors for central line infection

Answer 8

• Patient: immunosuppressed, malnourished
• Procedural: Sterile technique, skin preparation (Chlorhexidine), dressing (chlorhexidine gluconate square) and regular catheter care (change and clean caps)
• Anatomic: Higher in femoral lines
• Duration of catherization

Question 9

Commonest organism for line infection

Answer 9

• Staph aureus

- Strep epidermidis

Question 10

What sites used for central venous access?

Answer 10

• IJV
• SCV
• Femoral vein

Question 11

Anatomical landmark for IJV?

Answer 11

• Anterior and lateral to carotid in carotid sheath
• Lies on medial border of SCM clavicular head in triangle formed by 2 heads of SCM and clavicle
• Angle needle at 30 degrees towards sternal notch