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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
Indications for arthrocentesis
To evaluate synovial fluid To relieve pain by either removing fluid or injecting lidocaine and/or corticosteroids
26
Contraindications for arthrocentesis
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)
27
What size needles do you use for arthrocentesis?
22-27 gauge for injections 18-21 gauge for aspirations
28
How is an arthrocentesis performed?
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
29
Complications of arthrocentesis
Bleeding Infection Nerve trauma Adverse drug reaction Cartilage or tendon damage
30
Indications for CT-guided biopsy
Mass (lymph node, lung, liver, kidney, bone) Fluid collection
31
Contraindications for CT-guided biopsy
Coagulopathy Skin infection at site Uncooperative patient
32
How is CT-guided biopsy performed?
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
Complications of CT-guided biopsy
Allergy to contrast Renal failure from contrast Pain Bleeding Other complications based on site biopsies (PNA, hemothorax)
34
Indications for US-guided biopsy
Mass (lymph node, liver, kidney, thyroid, prostate) - NOT LUNG Fluid collection
35
Complications of US-guided biopsy
Coagulopathy Skin infection at site Uncooperative patient
36
How is US-guided biopsy performed?
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
Complications of US-guided biopsy
Pain Bleeding Other complications based on site biopsies (PNA, hemothorax)
38
Catheter inserted in the radial, brachial, or femoral artery for invasive arterial BP monitoring or recurrent ABGs
Arterial line
39
Arterial lines are NOT used for...
Medication administration
40
Contraindications for arterial lines
Coagulopathy Skin infection at site Uncooperative patient (it’s super painful/invasive)
41
How is an arterial line insertion performed?
Inform patient of procedure Locate the target artery Clean area with betadine Administer lidocaine if needed Puncture artery Withdraw blood Insert catheter
42
Complications of arterial line insertion
Pain Swelling Bleeding Damage to adjacent structures Infection Vascular complications (vasospasm, thromboembolism, dissection, pseudoaneurysm, or arteriovenous fistula formation)
43
How is an ABG obtained?
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
Indications for central venous catheter
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
Contraindications for central venous catheters
Distortion of anatomy/landmarks Coagulopathy Infection over insertion site Pneumothorax or hemothorax on contralateral side
46
What are the placement locations for central venous catheters?
Internal jugular, external jugular, subclavian, femoral, or brachial veins
47
Describe the internal jugular approach for central line placement
Insert either anterior or posterior to the SCM or between the eternal and clavicular heads of SCM Aim 30˚ towards xyphoid
48
Describe the supraclavicular approach for central line placement
1 cm above mid-point of clavicle Direct 30˚ towards opposite nipple
49
Describe the subclavian approach for central line placement
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
Complications of central venous catheters
Hemorrhage, hematoma Pneumothorax Hemothorax Arrhythmias Infection
51
Why do you do a follow up CXR after placing a central line?
Verify line position - desired position is tip of catheter in the SVC near the right atrium R/o complications
52
Indications for chest tube insertion
``` Pneumothorax Hemothorax Recurrent pleural effusion Empyema Penetrating chest trauma or flail chest ```
53
Contraindications for chest tube insertion
Coagulopathy Loculated pleural effusion Previous chest tube insertion, preventing re-insertion
54
Equipment needed for chest tube insertion
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
What size chest tube do you use for air?
#16-24
56
What size chest tube do you use for fluid or blood?
#34-40
57
Where are chest tubes placed for fluid or air evacuation?
In the 4th or 5th intercostal space in anterior axillary line or MCL
58
Prior to inserting the chest tube, what do you use to tunnel into the intercostal space?
Blunt dissection with a Kelley clamp to create a subcutaneous tunnel over up and OVER THE TOP of the rib
59
Why do you tunnel over the top of the rib when placing a chest tube?
To avoid nerves and vessels, as they run in the groove on the underside of the ribs
60
When using a chest tube for fluid evacuation, you should aim the tube _______ upon insertion
Inferiorly and posteriorly
61
When using a chest tube for air evacuation, you should aim the tube _______ upon insertion
Apically
62
Complications of chest tube insertion
Injury to heart, vessels, lung, or diaphragm Pneumothorax Hemorrhage Localized infection
63
What type of suture is used to secure a chest tube in place after placement?
Purse string suture
64
Indications for bone marrow aspiration/biopsy
``` Unexplained anemia, leukopenia, thrombocytopenia Abnormal peripheral smear Unexplained splenomegaly Fever of unknown origin Dx and staging of leukemia and lymphoma Bone marrow transplant ```
65
Contraindications for bone marrow aspiration and biopsy
Bleeding disorders Skin infection at site Uncooperative patient
66
_______ is the only site at which both aspiration and biopsy of bone marrow may be safely performed in the adult
Iliac crest Other locations: • Posterior superior iliac crest • Anterior iliac crest • Sternum
67
How do you prepare a patient for a bone marrow aspiration/biopsy
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
What anatomical landmarks guide you to the proper location for bone marrow aspiration and biopsy?
Three finger-widths from the midline and two finger-widths inferior to the iliac crest
69
You’ve prepped your patient for a BM biopsy and marked them up. Now what do you do?
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
Complications of bone marrow aspiration/biopsy
Bleeding - at biopsy site or retroperitoneal hemorrhage Infection Pain Perforation of eternal plate
71
What do you do to reduce complications of bone marrow aspiration/biopsy?
Place pressure on biopsy site for 1 hour following procedure

EMED Unit 3 (5 decks)

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