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EMED Unit 3 > Diagnostic and Therapeutic Procedures > Flashcards

Diagnostic and Therapeutic Procedures Flashcards

1
Q

When is cerumen impaction removal indicated?

A

EAC or TM obscured by cerumen

Hearing loss, tinnitus, vertigo, or otalgia

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2
Q

Contraindications for cerumen impaction removal

A

Uncooperative patient
Distorted/abnormal anatomy
Previous ear surgery
Suspected TM perforation

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3
Q

What equipment do you need for cerumen impaction removal?

A 
Ear curette
Syringe
Lukewarm tap water
Towels
Ear basin
Debris (solution to soften cerumen)
Suction
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4
Q

How do you prepare your patient for cerumen impaction removal?

A

Explain procedure and risks to patient

Stress importance of remaining still

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5
Q

How is cerumen impaction removal performed?

A

Seat patient, visualize canal and cerumen with otoscope

Place posterior traction on ear

Remove cerumen with curette or suction

If irrigation is needed:
• Fill syringe with lukewarm TAP water
•Tilt patient head to side being irrigated and hold basin
•Direct water towards occiput

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6
Q

Possible complications of cerumen impaction removal

A

TM perforation/damage
Otitis externa
Vertigo/N/V/tinnitus
EAC wall abrasions/bleeding

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7
Q

What is a subunugal hematoma?

A

Bleeding between the nail bed and finger/toenail caused by trauma

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8
Q

Indications for evacuation of a subunugal hematoma

A

Visible, painful hematoma

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9
Q

Contraindications for evacuation of a subunugal hematoma

A

Crushed or fractured nail bed

Hematoma involving >50% of nail (consider laceration of nail bed)

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10
Q

Equipment needed for evacuation of subunugal hematoma

A

Bunsen burner

Metal paper clip

Forceps or hemostat

Cautery unit

Preparation:
• Wash finger/toe

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11
Q

Indications for nasogastric (NG) tube insertion

A

Decompress stomach (gastric outlet obstruction, ileus)

Small bowel obstruction****

Gastric lavage (med overdose, bleeding)

Enteral feeding

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12
Q

Contraindications for NG tube insertion

A

Basilar skull fracture***

Facial trauma**

Nasal obstruction (BOOGERS)

Esophageal disease (strictures, diverticuli, recent surgery) b/c can lead to perforation

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13
Q

What sizes do NG tubes come in?

A

Smaller the number, smaller the tube

3-8 French for peds

10-18 French for adults (14 Fr is average)

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14
Q

Orogastric NG tubes are …

A

Large bore, designed for gastric lavage

Used for critically ill patients

May need sedation for insertion

Peds: 24-28 Fr
Adults: 36-40 Fr

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15
Q

NG tubes used for Feeding are …

A

Smaller, softer tubes

Designed to be left in place for longer periods of time

Tendency to clog, so convert meds to elixir or IV if possible; flush tube after meds given

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16
Q

How do you prepare a patient for NG tube insertion?

A

Informed consent/explanation

Expect heightened patient anxiety

Inquire/examine for nasal obstruction

Preferably have patient in sitting position

Estimate length of tube needed (tip of nose to ear; ear to xyphoid)

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17
Q

Procedure for inserting NG tube

A

Lubricate end of tube, insert along floor of nose slowly/gently

Have patient flex neck forward until tube passes esophagus

Once patient can feel it in the back of throat have them swallow

Don’t force tube

If tube curls in posterior pharynx, pull back slightly and try again

Verify position by injecting air and listening with stethoscope (should hear burp)

Secure with type to nose, connect to suction if necessary

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18
Q

Complications of NG tube insertion

A

Patient discomfort

Trauma to nares at insertion/bleeding

Sinusitis on side of tube

Gastric irritation (esp if tube lying on gastric mucosa)

Aspiration PNA if using for feeding
• Keep HOB elevated
• Monitor patient and start feedings slow, advance as tolerated

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19
Q

Does a feeding tube prevent aspiration PNA?

A

NOPE

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20
Q

Contraindications for I&D of an abscess

A

Furuncle or abscess with triangle of bridge of nose or corners or mouth

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21
Q

What size blade do you use for I&D of an abscess?

A

No. 11

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22
Q

Why do you inject lidocaine around the abscess but not into the abscess itself?

A

B/c the acidic nature of pus weakens the local anesthetic

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23
Q

What does wound care for I&D of an abscess entail?

A

Wound check in 24-48 hours

Repack daily (if applicable) - can teach pt to do it themselves

If fever, chills, inc pain, redness, swelling, or streaking, RTC

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24
Q

Complications of I&D

A 
Pain
Recurrence
Scar
Worsening infection 
Fistula formation
Osteomyelitis
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25
Q

Indications for arthrocentesis

A

To evaluate synovial fluid

To relieve pain by either removing fluid or injecting lidocaine and/or corticosteroids

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26
Q

Contraindications for arthrocentesis

A

Cellulitis or broken skin over joint - your dumb ass would be introducing bacteria to the joint space, and that’s no bueno

Coagulopathy

Infected bursa

Bacteremia (unless joint is the cause)

Joint prosthesis (refer to ortho)

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27
Q

What size needles do you use for arthrocentesis?

A

22-27 gauge for injections

18-21 gauge for aspirations

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28
Q

How is an arthrocentesis performed?

A

Inform patient of procedure

Anatomically approach each joint, palpate, and mark area

Clean area with betadine

Administer lidocaine

Insert needle and aspirate to insure no blood return

Aspirate or inject site

Collect fluid for analysis if needed

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29
Q

Complications of arthrocentesis

A

Bleeding

Infection

Nerve trauma

Adverse drug reaction

Cartilage or tendon damage

30
Q

Indications for CT-guided biopsy

A

Mass (lymph node, lung, liver, kidney, bone)

Fluid collection

31
Q

Contraindications for CT-guided biopsy

A

Coagulopathy

Skin infection at site

Uncooperative patient

32
Q

How is CT-guided biopsy performed?

A

Obtain informed consent

Place patient in CT scanner

Prepare in sterile fashion

Clean the area with betadine

Administer lidocaine

Use real-time CT images to ensure the needle reaches the correct area

33
Q

Complications of CT-guided biopsy

A

Allergy to contrast

Renal failure from contrast

Pain

Bleeding

Other complications based on site biopsies (PNA, hemothorax)

34
Q

Indications for US-guided biopsy

A

Mass (lymph node, liver, kidney, thyroid, prostate) - NOT LUNG

Fluid collection

35
Q

Complications of US-guided biopsy

A

Coagulopathy

Skin infection at site

Uncooperative patient

36
Q

How is US-guided biopsy performed?

A

Obtain informed consent

Prepare in sterile fashion

Clean the area with betadine

Administer lidocaine

Use real-time US images to ensure the needle reaches the correct area

37
Q

Complications of US-guided biopsy

A

Pain

Bleeding

Other complications based on site biopsies (PNA, hemothorax)

38
Q

Catheter inserted in the radial, brachial, or femoral artery for invasive arterial BP monitoring or recurrent ABGs

A

Arterial line

39
Q

Arterial lines are NOT used for…

A

Medication administration

40
Q

Contraindications for arterial lines

A

Coagulopathy

Skin infection at site

Uncooperative patient (it’s super painful/invasive)

41
Q

How is an arterial line insertion performed?

A

Inform patient of procedure

Locate the target artery

Clean area with betadine

Administer lidocaine if needed

Puncture artery

Withdraw blood

Insert catheter

42
Q

Complications of arterial line insertion

A

Pain

Swelling

Bleeding

Damage to adjacent structures

Infection

Vascular complications (vasospasm, thromboembolism, dissection, pseudoaneurysm, or arteriovenous fistula formation)

43
Q

How is an ABG obtained?

A

Blood is drawn from an artery (usually radial, sometimes brachial or femoral)

Blood collected with an anticoagulant, placed on ICE, and taken quickly to the lab for prompt analysis

44
Q

Indications for central venous catheter

A

Hemodynamic/CV pressure monitoring

Medication administration (pressors, chemo)

TPN

Lack of peripheral sites

Emergent need for vascular access

Hemodialysis

To avoid repetitive blood draws

Administration of abx in home setting

45
Q

Contraindications for central venous catheters

A

Distortion of anatomy/landmarks

Coagulopathy

Infection over insertion site

Pneumothorax or hemothorax on contralateral side

46
Q

What are the placement locations for central venous catheters?

A

Internal jugular, external jugular, subclavian, femoral, or brachial veins

47
Q

Describe the internal jugular approach for central line placement

A

Insert either anterior or posterior to the SCM or between the eternal and clavicular heads of SCM

Aim 30˚ towards xyphoid

48
Q

Describe the supraclavicular approach for central line placement

A

1 cm above mid-point of clavicle

Direct 30˚ towards opposite nipple

49
Q

Describe the subclavian approach for central line placement

A

Good landmarks, more comfortable for patient, but higher risk of pneumothorax

~2cm below midpoint of clavicle, direct needle to manubrium while maintaining a shallow angle of 15˚

“Walk” under clavicle to find venous access

50
Q

Complications of central venous catheters

A

Hemorrhage, hematoma

Pneumothorax

Hemothorax

Arrhythmias

Infection

51
Q

Why do you do a follow up CXR after placing a central line?

A

Verify line position - desired position is tip of catheter in the SVC near the right atrium

R/o complications

52
Q

Indications for chest tube insertion

A 
Pneumothorax
Hemothorax
Recurrent pleural effusion
Empyema
Penetrating chest trauma or flail chest
53
Q

Contraindications for chest tube insertion

A

Coagulopathy
Loculated pleural effusion
Previous chest tube insertion, preventing re-insertion

54
Q

Equipment needed for chest tube insertion

A

Betadine, gloves, drapes, protective eyewear
Local anesthesia
Needles w/ 10cc** syringe
Scalpel
Chest tube tray
Chest tube (#16-24 for air/#34-40 for fluid blood)**
Suction unit/wall suction
Suture, dressing materials, Vaseline gauze

55
Q

What size chest tube do you use for air?

A

16-24

56
Q

What size chest tube do you use for fluid or blood?

A

34-40

57
Q

Where are chest tubes placed for fluid or air evacuation?

A

In the 4th or 5th intercostal space in anterior axillary line or MCL

58
Q

Prior to inserting the chest tube, what do you use to tunnel into the intercostal space?

A

Blunt dissection with a Kelley clamp to create a subcutaneous tunnel over up and OVER THE TOP of the rib

59
Q

Why do you tunnel over the top of the rib when placing a chest tube?

A

To avoid nerves and vessels, as they run in the groove on the underside of the ribs

60
Q

When using a chest tube for fluid evacuation, you should aim the tube _______ upon insertion

A

Inferiorly and posteriorly

61
Q

When using a chest tube for air evacuation, you should aim the tube _______ upon insertion

A

Apically

62
Q

Complications of chest tube insertion

A

Injury to heart, vessels, lung, or diaphragm

Pneumothorax

Hemorrhage

Localized infection

63
Q

What type of suture is used to secure a chest tube in place after placement?

A

Purse string suture

64
Q

Indications for bone marrow aspiration/biopsy

A 
Unexplained anemia, leukopenia, thrombocytopenia
Abnormal peripheral smear
Unexplained splenomegaly
Fever of unknown origin
Dx and staging of leukemia and lymphoma
Bone marrow transplant
65
Q

Contraindications for bone marrow aspiration and biopsy

A

Bleeding disorders
Skin infection at site
Uncooperative patient

66
Q

_______ is the only site at which both aspiration and biopsy of bone marrow may be safely performed in the adult

A

Iliac crest

Other locations:
• Posterior superior iliac crest
•Anterior iliac crest
•Sternum

67
Q

How do you prepare a patient for a bone marrow aspiration/biopsy

A

Pre-medicate patient

Place patient in the lateral decubitus position

Palpate the anatomical landmarks (three finger-widths from the midline and two finger-widths inferior to the iliac crest) - mark area

Prepare in a sterile fashion

Clean with betadine

Administer lidocaine

68
Q

What anatomical landmarks guide you to the proper location for bone marrow aspiration and biopsy?

A

Three finger-widths from the midline and two finger-widths inferior to the iliac crest

69
Q

You’ve prepped your patient for a BM biopsy and marked them up. Now what do you do?

A

Make incision, and insert BM aspiration needle perpendicular to the skin

Advance it to the periosteum

Point needle in the direction of the anterior superior iliac spine and twist needle

A “give” is felt when the needle enters the marrow cavity

Aspirate and remove needle

Insert biopsy needle and advance into the cortical bone

70
Q

Complications of bone marrow aspiration/biopsy

A

Bleeding - at biopsy site or retroperitoneal hemorrhage

Infection

Pain

Perforation of eternal plate

71
Q

What do you do to reduce complications of bone marrow aspiration/biopsy?

A

Place pressure on biopsy site for 1 hour following procedure

EMED Unit 3 (5 decks)

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