Exam 4 Therapeutic Procedures

Question 1

Cerumen Impaction Removal indicated when? (4)

Answer 1

Hearing loss
Tinnitus
Vertigo
Otalgia (earache)

Question 2

Cerumen Impaction Removal contraindicated when? (4)

Answer 2

Uncooperative
Distorted/abn anatomy
Prior ear surgery
Suspect TM perf

Question 3

Cerumen Impaction Removal complications? (4)

Answer 3

TM perf
Otitis externa
Vertigo/NV/Tinnitus
Internal Auditory Canal abrasion

Question 4

Subungual Hematoma is?

Evacuation indicated when?

Contraindicated when? (2)

Answer 4

Bleed b/w nail and digit from trauma

Visible/Painful

Crushed/Fractured bed
Involves > 50% of nail

Question 5

Subungual Hematoma Evacuation procedure?

Answer 5

Heated paperclip or cautery ->

place on nail

Question 6

Nasogastric Tube Insertion indicated when? (4)

Answer 6

Decompress stomach from outlet obstruction or ileus
SBO
Gastric lavage for overdose or bleeding
Enteral feeding

Question 7

Nasogastric Tube Insertion contraindicated when? (4)

Answer 7

Basilar skull fxr
Facial trauma
Nasal obstruction
Esophageal dz

Question 8

NG Tube complications? (3)

Answer 8

Sinusitis
Gastric irritation
Aspiration PNA (keep head elevated)

Question 9

I&D indicated when?

C/I when?

Answer 9

Abscess

Located in nasolabial folds (drain into sphenoid sinus)

Question 10

I&D F/U?

Complications? (4)

Answer 10

Wound check 24-48 hrs
Repack daily

Pain
Recurrence
Scar
Worse infection

Question 11

Arthrocentesis indicated when? (2)

C/I when? (5)

Answer 11

Eval fluid
Pain relief

Cellulitis or broken skin
Coagulopathy
Infected bursa
Bacteremia
Joint prosthesis (refer)

Question 12

Arthrocentesis needle gauges?

Complications? (5)

Answer 12

22-27 for injection
18-21 for aspiration

Bleed
Infection
NN trauma
Cartilage/tendon damage
Drug rxn

Question 13

Thoracentesis indicated when? (3)

Answer 13

Remove air/fluid from chest (pleural effusion, empyema, pneumothor)
Fluid analysis
Instill sclerosing meds

Question 14

Thoracentesis C/I when? (2)

Answer 14

Coagulopathy

Uncontrolled cough/hiccups

Question 15

Thoracentesis lidocaine injected where?

Aspiration needle inserted where? (3)

Tip of needle pointing up for what?

Down for what?

Answer 15

Above rib to avoid neuromuscular bundle that runs below rib

1-2 ICS below level of ↓BS, dull percussion
Above 9th rib to avoid diaphragm puncture
Midway b/w spine and post axillary line

Up for air
Down for fluid
(air will rise above fluid)

Question 16

Thoracentesis complication? (3)

Answer 16

Pneumo- hemothorax
Diaphragm puncture
Re-expansion edema (Do not take > 1L, do not perform bilaterally)

Question 17

Paracentesis indicated when?

C/I when? (5)

Answer 17

Ascites (dx and therapeutic)

Acute abdomen
Coag
Distended bladder/bowel
Preggo
Infection at site

Question 18

Paracentesis procedure?

Complications? (3)

Answer 18

Pt supine w/ raised HOB or L lat decubitus
Insert 1/3 distance b/w umbilicus and ant iliac crest

Rare: perf, infection, hematoma

Question 19

Lumbar Puncture indicated for diagnostics when? (5)

Answer 19

CNS infection
MS
SAH
Tumor
Normal Pressure Hydrocephalus

Question 20

Lumbar Puncture indicated for tx when? (2)

Answer 20

Admin meds (anesthesia, chemo, ABX)
Remove CSF (pseudotumor cerebri)

Question 21

Lumbar Puncture C/I when? (3)

Answer 21

Intracranial lesion (focal deficit, papilledema)
Local skin infect
Coagulopathy or thrombcytopenia

Question 22

Lumbar Puncture insert where?

Answer 22

L4-5

20-30° towards umbilicus

Question 23

Opening pressure at lumbar puncture tells us?

Normal pressure values?

Answer 23

↑ pressure = tumor, infect, bleeding, MS

N lying pressure = 5-14 mmHg
Sitting = 5-27

Question 24

Lumbar Puncture complications? (4)

Answer 24

CSF leak w/ HA
Infection
Nerve impingement
Herniation

Question 25

Central Venous Catheter indicated when? (7)

Answer 25

``` Hemo/CV pressure monitoring Meds (pressors, chemo, ABX) TPN No viable peripheral sites Emergent vascular access Hemodialysis Repetitive blood draws ```

Question 26

Central Venous Catheter C/I when? (4)

Answer 26

Distorted landmarks Coag Infection at site Pneumo- hemothorax on contralat side

Question 27

Central Venous Catheter sites? (4)

Answer 27

Internal/External jugular Subclavian vv Femoral vv Brachial vv

Question 28

Central Venous Catheter landmarks for Internal Jugular approach?

Answer 28

Apex of triangle formed by sternal and clavicular heads of SCM mm and clavicle

Question 29

Central Venous Catheter: Benefits of subclavian approach? (2) Drawbacks?

Answer 29

Good landmarks More comfortable for pt Higher risk of pneumothor

Question 30

Central Venous Catheter complications? (4)

Answer 30

Hemorr Pneumo- hemothorax Arrhythmia Infection

Question 31

Immediately post-placement, do what?

Answer 31

CXR to verify placement and no hemo- pneumo- Tip should be in SVC near RA

Question 32

Chest Tube indicated when? (4)

Answer 32

Pneumo- hemothorax Recurrent pleural effusion Empyema Penetrating chest truma

Question 33

Chest Tube C/I when (3)

Answer 33

Coag Loculated pleural eff (confined to one or more fixed pockets) Previous chest tube

Question 34

Chest Tube insertion location? Procedure? (3 steps)

Answer 34

4th/5th ICS, anterior axillary or MCL 2-4 cm incision parallel to ICS Blunt dissection -> SQ tunnel over top of next rib F/U CXR

Question 35

Chest Tube complications? (3)

Answer 35

Heart/vessel/lung/diaph injury Pneumo-/Hemo- Infection

Question 36

Bone Marrow Aspiration/Bx indicated when? (6)

Answer 36

``` Unexplained anemia/leuko or thrombo penias Abn periph smear Unexplained splenomegaly Unexplained fever Dx/stage leukemia/lymphoma BM transplant ```

Question 37

Bone Marrow Aspiration/Bx C/I when? (2)

Answer 37

Bleed disorder | Skin infection

Question 38

Bone Marrow Aspiration/Bx site?

Answer 38

Iliac crest -> | 3 fingers from midline and 2 inferior to iliac crest

Question 39

Bone Marrow Aspiration/Bx complications? (4)

Answer 39

Bleed Infection Pain Perf of sternal plate