Instruments Flashcards
Arterial Blood Gas Syringe
Arterial Blood Gas samples are a useful adjunct in the acute environment. They are a version of point-of-care testing (POCT) and therefore you can attain immediate results.
Key areas tested with the blood test include:
pH – acidosis/alkalosis
pO2 and pCO2 – identification of respiratory failure (arterial)
Bicarbonate – renal and compensation of acidosis/alkalosis
Lactate – poor perfusion
Hb – anaemia
Na+/K+ quick testing of electrolytes – handy in monitoring and treatment of hyperkalaemia.
Absorbable Sutures
Absorbable sutures are broken down by physiological processes such as enzymatic degradation and hydrolysis.
Patient clinical status can affect the rate of absorption, e.g. sepsis.
Monocryl – monofilament, increased throws for stable knot (9).
Vicryl – polyfilament, less throws (3) but has increased fraying issues and local tissue inflammation.
Tensile strength of sutures rely on diameter of thread.
Blood Bottles
Blood bottles are colour coded to use for different tests.
Purple – contains EDTA. Used for haematology.
Pink – contains EDTA. Used for group and save and crossmatch.
Blue – contains buffered sodium citrate. Used for coagulation screening.
Yellow/gold – known as SST. Contains silica particles and serum separating gel. Used for a variety of tests that require separated serum for analysis, including immunology, microbiology, biochemistry, endocrinology, toxicology, oncology, U+E and liver function.
Grey – contains sodium fluoride and potassium oxalate. Used for glucose and lactate tests.
Red – contains silica particles. Used for sensitive tests including toxicology, drug levels, antibodies, hormones and bacterial and viral serology.
Dark green – contains sodium heparin. Used for ammonia, renin, aldosterone and insulin tests.
Light green – Known as PST. Contains lithium heparin and a plasma separator gel. Used for routine biochemistry.
Rust Top- Viral Immunology.
Blood Culture Bottles
These are two blood culture bottles, one for aerobic bacteria (blue top) and one for anaerobic bacteria (purple top). The blood is injected in a sterile manner into the bottles using a different needle from the one the blood was drawn with.
Blood cultures are a useful investigation in a case of pyrexia or suspected systemic sepsis.
Remember, fill the aerobic bottle first if you are using a vacutainer.
Breast Implants
These are breast implants. They come in many shapes and sizes to suit different body habitus. They can be round or anatomical shaped. Made from Silicone. Used for breast augmentation and breast reconstruction after mastectomy. Also in gender reassignment.
They last for about 10-15 years on average. Over time they degrade and can rupture.
There is a very rare risk of ALCL – Anaplastic Large-Cell Lymphoma – a recently described complication.
Complications: Rupture, Infection, Capsular contracture, Erosion, through the skin, Migration, ALCL.
Catgut Suture
This is catgut suture, which is an example of a natural absorbable suture. Catgut as been replaced my many of the newer synthetic absorbable materials, however you will still see it being used in the formation of stomas and circumcisions.
Catheter Bag
A catheter bag includes a flexible tube used to empty the bladder and collect urine in a drainage bag.
They can either be inserted through the tube that carries urine out of the bladder (urethral catheter) or through a small opening made in lower abdomen (suprapubic catheter).
Central Line Insertion Pack
Seldinger central line kits include a 3-5 lumen cannula, guide wire, dilator, scalpel, and introducer needle.
Central venous catheters are placed often into the subclavian or internal jugular veins via ultrasound. They are useful in the delivery of medications/fluids that may be harmful orally or peripherally. Blood tests and central venous pressures can also be obtained.
Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes.
Complications on insertion include: pneumothorax, sepsis, thrombosis and misplacement.
Chest Drain Bottle
The are multiple drainage systems that can be used once a chest drain has been inserted.
Passive drainage – underwater seal which employs a positive expiratory pressure and gravity to drain the pleural space. This helps recreate a negative pressure in the pleural space. If you look carefully on these there will be a line called prime level which is filled with sterile water. The chest drain tubing is connected to a tube which is under the sterile water and therefore acts as a water seal.
After a chest drain has been inserted you can see bubbling in the water as the air leaves the pleural space. The chest drain bottle can also be used to collected blood, fluid and pus from the pleural space. The system can be driven by attaching suction to the top of the bottle making it an example of a active closed drainage system.
CSF Manometer
CSF Manometers are key in the identification of opening pressures and represent Intracranial Pressure during Lumbar Puncture.
Measurement is in cm H2O.
Current accepted opening pressures (normal) are 10-18 cm H2O if patient is lying on their side, 20-30 cm H2O when sat up.
Devers Retractor
This is a type of retractor which is used in open abdominal surgery to allow the surgeon to operate.
There are different sizes and types of retractors available, you may frequently be asked to use one during you clinical training when you are assisting in theatre.
Disposable Rigid Sigmoidoscope
This is a disposable rigid sigmoidoscope, which is used for the inspection of the rectum and lower sigmoid colon.
After explaining to the patient what you are about to do, you must attach a light source and a air pumping device. The patient is placed in the left lateral position and a digital rectal examination is performed. The sigmoidoscope is then lubricated with jelly and inserted pointing towards the umbilicus. Air is pumped into the rectum to allow you see the direction of the rectal lumen.
Biopsies can also be taken of rectal mucosa through the sigmoidoscope e.g. in a case of ulcerative colitis
Drainage Bag
This is a drainage bag which can be connected top either a nasogastric tube or a drain coming out of the abdomen. Drainage relies on gravity so this is an example of a closed passive drainage system.
Endotracheal Tube with Tape and Syringe
An endotracheal tube is a definitive airway.
Used commonly in trauma cases, surgery with general anaesthetic and in patients with a GCS <8.
The tube is inserted into the trachea via the oropharynx using a laryngoscope and Eschmann Tracheal Tube Introducer (ETTI – or otherwise known as the bougie). Usually performed by an anaesthetist.
It is connected to oxygen and ensures adequate oxygen/CO2 gaseous exchange.
After inserting the tube, a balloon at the end of the tube is inflated with air through the blue side port. Position of the tube is checked by looking for symmetrical rising of the chest on ventilation, breath sounds bilaterally and no gurgling over the epigastrium indicating oesophageal intubation
The tape secures the tube in the airway whilst balloon inflation maintains position and protects airway from aspiration.
Complications include (but not exhaustive) inappropriate placing (oesophageal), injury to larynx, pneumothorax, atelectasis and infection.
Epidural Insertion Pack
An epidural insertion pack contains:
Touhy/Epidural needle – Touhy type needle is provided with clear depth marking for accurate insertion depth reading.
Epidural catheter- It is specially designed for short term and long term anaesthesia and pain relief.
Epidural catheter adapter – This catheter adapter is for safe and secure attachment to the catheter for convenience of the procedure
Faeces Sample Pot
Stool samples enable the identification of pathogens that are infecting the gut. Ideally, Bristol stool chart 5,6 and 7 warrant samples.
Tests that can be used to identify cause of symptoms include:
MCS – takes up to 4 days for result.
Rotavirus/Adenovirus/Norovirus – same day result
Glutamine Dehydrogenase (GDH) (C.diff)
C.Diff Toxin test only performed if GDH is positive
C.Difficile ribotyping results take up to 2 weeks
Microscopy for Ova, Cysts and parasites – 4 days
Helicobacter antigen testing – up to a week
Feeding NG Tube
This is a feeding nasogastric tube (clinifeed tube) which is used to long term enteral nutrition in patients. It is thin bore and soft making it more comfortable for patients, it is also made of silastic which blocks less often.
After explaining to the patient what you are about to do the tube is inserted into the nostril after it has been lubricated. These tubes come with a wire inside them to aid their introduction, you advance the tube as the patient swallows. Correct position of the tube is checked by x-raying for the wire. When you are happy with the position of the tube the wire is removed and the feed attached in a sterile manner.
Five Percent Dextrose
This is a bag of 5% dextrose, which can be used in conjunction with normal saline to provide the normal daily fluid requirement for a patient.
One litre of 5% dextrose contains 50g of dextrose in 1 litre of water.
It should be remembered that because the sugar in this fluid is metabolised to carbon dioxide and water you are essentially giving them water.
Fluid Giving Set
Regularly used on wards to give IV fluids, administration of IV medications including antibiotics and blood products.
Forceps
Two common types of forceps include non-toothed (top) and toothed (bottom).
These are often known as Ramsay Forceps (dissecting forceps). They are used to grasp edges of tissue and the general rule is that toothed should only be used for Skin.
Once in peritoneal cavity, the general rule is that only non-toothed should be used.
Grasp these forceps between thumb and fore-finger in a pincer grip.
Fracture Plate
This is a plate that is used in conjunction with screws to internally fix a bone fracture.
Gelofusin
This is 500ml of gelofusin which is an example of an artificial colloid solution.
Colloid solutions raise the plasma oncotic pressure and hence expand the intravascular compartment. There are other colloids and some available are natural e.g. albumin and blood. Colloids are useful in cases of shock e.g. due to sepsis or hypovolaemia.
Hartmann/Plasmalyte Solution
This is an example of a crystalloid solution, which contains sodium, chloride, bicarbonate and lactate.
It has a similar composition to the extracellular fluid.
It can be used to provide the normal daily fluid requirement of a patient or to supplement the patient for additional loses.
Hartmann’s solution is a favourite solution of anaesthetists and is the fluid advocated to be given initially in trauma in the Advanced Trauma and Life Support (ATLS) guidelines.
Hemiarthroplasty
This is a hemiarthoplasty hip prosthesis.
It is used in cases of intracapsular fractures of the neck of femur avascular necrosis of the femoral head is a common complication.
Hickman Line
This is a an example of a long term central venous line which is inserted in a similar way to a central line (usually subclavian).
The remnant of the line is tunnelled subcutaneously, which decreases the incidence of line infection.
These are indicated for long-term parenteral nutrition, long-term intravenous antibiotic therapy and chemotherapy.
Hip Replacement
A total hip replacement consists of two distinct parts:
The femoral stem with femoral head
The polyethylene acetabular cup that is inserted into the acetabulum.
Total hip replacements are often used to replace a hip joint, for instance in severe osteoarthritis.
Complications with THRs include DVTs, infection and dislocation (2%).
Histology Specimen Pot
Histology specimen pots are routinely used in surgery. Biopsies, resected tumours etc can be placed here and set in formalin.
They form a part of the WHO Surgical Safety Checklist. There is a distinct prompt in the “Sign Out” section to make sure histology specimens are correctly labelled.
IM Femoral Nail
This is an intramedullary femoral nail which is used to internally fix femoral shaft fractures.
Interlocking screws are used to fix the nail. They are usually removed after 12 / 18 months.
Instillagel
Instillagel is a sterile gel containing a local anaesthetic and lubricant gel.
It is used for male and female catheterisation.
Intravenous Cannula & Octopus
Multiple different cannula systems are available:
The newer – premade dual lumen cannula systems requires no saline preparation and allows the user to take blood samples directly post insertion.
Lumens will then need to be flushed to prevent clot formation.
Old systems may require a pre-flushed octopus as an adjunct.
Cannulae come in different sizes, 22G (Blue) and 20G (Pink) are common on wards. 16G (Grey) are common in fluid resus and trauma.
If you wish to give fluid quickly the cannula must be short and large bore.
Laparoscopic Port
This is a Laparoscopic post which is used during Laparoscopic procedures e.g. Laparoscopic cholecystectomy.
These ports allow the surgeon to insert a telescope and instruments in the patient.
Laryngoscope
A laryngoscope is used to aid intubation, visualisation of larynx to aid diagnosis of vocal problems and strictures.
There are multiple different forms of blades – curved (Macintosh) as seen in the picture. Straight blades (Miller) are also used.
Inexperienced users of laryngoscopes can cause severe harm to the patient including mild soft tissue injury, laryngeal and pharyngeal scarring, ulceration and abscess formation.
Laryngeal Mask & Airway Adjuncts
iGels and laryngeal mask airways (LMA) are supraglottic airway devices that are used as a step prior to intubation. They are very good for elective procedures, cardiac arrests and prehospital airway management. They have benefits that include reduced trauma to the oropharynx (seen with intubation) and therefore can be used to reduce hospital stays in elective patients.
iGels contain a thermoplastic elastomer (styrene) that moulds to perilaryngeal framework with patient temperature. The device tip extends into the oesophageal opening, has its own gastric channel to allow the passing of NG tube into the stomach for gastric emptying. The iGel also seals off the oropharyngeal opening from the larynx, preventing aspiration. iGel can also be used as conduit for intubation. Insert with number facing towards you when behind the patient.
LMAs are also an excellent choice of airway management, however they do not eliminate aspiration risk. Inflation of the device can also cause pressure lesions and nerve palsies.
Leg Bag
This is a leg bag which is attached to a urinary catheter.
The bag is strapped to the leg of the patient and is indicated for patients who are mobile and have either a short or long term indwelling urinary catheter.
A man who suffers with incontinence following sphincter damage after multiple TURPs.
Monopolar Diathermy Handle
Monopolar diathermy is used for coagulation and dissection of tissue during open or laparoscopic surgery.
Nasal Cannulae
Nasal cannula are commonly used mode of oxygen delivery both in hospital and in the community.
It is widely used to carry 1-3L of oxygen per minute (can be upto 5L/min). This delivers between 28-44% of oxygen.
These cannulae differ from high-flow therapy (NIV).
Common issues are nasal sores and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise.
Nasal Speculum
Thudichum Nasal Speculum is designed to open and expand the nasal cavity.
Nasopharyngeal Airway
This is a nasopharyngeal airway which is inserted into the nose using a rotational action.
It is used to provide an airway in people with a decreased level of consciousness or decreased gag reflex. The diameter tube should be sized against the patients own little finger distal phalanx. A safety pin is placed in the end of the tube to prevent it being inhaled.
Nebuliser Mask + Chamber
Nebuliser mask and chamber can be used to administer all commonly prescribed bronchodilators for respiratory conditions. Aerosol drug effectiveness depends on the quality of its delivery to the lungs.
Needle Holders
These are special forceps designed to hold the needle to allow the surgeon to suture accurately.
Neurology Kit
Neurology kit includes:
1x 128Hz tuning fork (vibration for joints)
1x 512Hx tuning fork (Weber’s and Rinne’s)
Neurotips for blunt/sharp sensation in sensory examination
Orange stick – to test Babinski reflexes (plantar reflex)
Tendon hammer – reflexes.
Other aids may include: Snellen chert, ophthalmoscope and tongue depressor.
Non-Absorbable Sutures
Ethilon (nylon) is monofilament – therefore requires 9 throws to maintain a strong knot over time.
Prolene is another example of non-absorbable suture.
Both ethilon and prolene have high tensile strength and low-reactivity. However, ethilon knots are more likely to loosen over time. Therefore usually limited to percutaneous closure.
Non-absorbable sutures are used in longer-term tissue approximation:
Percutaneous wound closure
Bowel anastomosis (Prolene)
Vascular anastomosis (Prolene)
Non-Rebreather Mask
A non-rebreather mask (NRB) is used to assist in the delivery of oxygen therapy. It requires that the patient can breathe unassisted.
The non-rebreather mask covers both the nose and mouth of the patient and attaches with the use of an elastic cord around the patient’s head. The NRB has an attached reservoir bag, that connects to an external oxygen tank or Bulk Oxygen Supply system.
The flow rate is 10-15 litres/minute and it can deliver up to 90% oxygen concentration.
Normal Saline
Normal (0.9%) Saline. Normal saline is an example of a crystalloid solution which contains 153mmol of NaCl.
It can be used to provide the normal daily fluid requirement for a patient or to replace additional losses e.g. vomit or diarrhoea.
Oropharyngeal Airway
This is used to provide an airway for a patient where there is an impaired level of consciousness.
It is sized by measuring the distance from the angle of the mouth to the angle of the jaw. It is inserted into the mouth upside down and rotated within the oral cavity. It is inserted the correct way up in children.
PICC Line
A commonly used IV access option is the peripheral IV central catheter, or PICC line, which shares features of both central and peripheral venous access. PICC lines are suitable for long-term vascular access for blood sampling, chemotherapy administration, and infusion of hyperosmolar solutions such as those used for total parenteral nutrition. A PICC line is composed of a thin tube of biocompatible material and an attachment hub that is inserted percutaneously into peripheral veins and advanced into a large central vein.
Proctoscope
This is a proctoscope, it is used to visualise the anal canal and lower rectum, it is also used when injecting or banding haemorrhoids.
After explaining the procedure to the patient, the patient is placed in the left lateral position and a digital rectal examination is performed. The proctoscope is then attached to a light source and lubricated prior to its insertion into the rectum.
Ryles NG Tool
This is a Ryles nasogastric tube which is primarily used for decompression (drip and suck) in bowel obstruction, but can also be used to insert drugs or contrast into the GI tract.
After explaining what you are about to do to the patient, you will require a NG tube which has been in the fridge as it is stiffer, some lubricant, a bladder syringe, a drainage bag and pH dipstick.
The correct position of the tube is checked by aspirating gastric contents and checking for acidity on pH dipstick, if this is unavailable then air can be inserted to the tube and the epigastrium auscultated for bubbling. Finally, an x-ray can be taken to identify the tube.
Once the tube is in the correct position a bag is attached and it is taped to the patients face.
Scalpel
There are two types of scalpels: disposable (on top) and non-disposable (below). The blade of the non-disposable scalpel must be changed.
Surgical blades, or scalpels, are used for cutting skin and tissue during surgical procedures. There are different types of blades specific to the type of procedure. Surgical blades vary by size and shape. The number of the blade indicates the blade size and shape e.g. 10, 11, 12, 15, 22.
Seldinger Chest Drain Insertion Pack
Chest drain seldinger can come in a variety of forms, (Rocket, Portex etc)
These can be used on the wards and in outpatients to insert chest drains.
Indications include: Pneumothorax (in ventilated patient, tension pneumothorax after needle relief, persistent pneumothorax or large spontaneous pneumothorax); symptomatic malignant pleural effusions; empyema, traumatic haemothorax.
Self-Inflatable Bag-Valve-Mask
Very useful in delivering high levels of oxygen even at low-flow rates. Can deliver 100% oxygen with flows above 10L/min.
Shouldered Syringe
This a syringe used for the injection of haemorrhoids with 5% phenol in almond oil.
The injection is performed in conjunction with a proctoscope. The injection is performed above the dentate line as it is insensitive.
Specimen Swabs
Sterile specimen swabs are used routinely in MRSA screening (nasopharyngeal and rectal).
Bluetop Transwab Amies are to recover aerobes, anaerobes and fastidious organisms.
These swabs are excellent to aid gram stains.
They are also used to take specimens from wounds, skin, urogenitalia and throat.
Spinal Needles
There are two types of spinal needle. Traumatic needles are cutting needles (top picture). These are related with higher risk of post-LP headaches (35%), severe headaches that may require blood patching to help treat the symptoms and additional hospital visits for pain.
Pencil-point (atraumatic) needles are blunt tipped, allowing for blunt dissection of the anatomy rather than cutting. It is now the needle of choice for LP (not for epidural) as they have significantly the incidence of post-LP headaches reduced (relative risk of 0.4 compared to traumatic) and backache.
Stiff Neck Cervical Collar
This is a stiff neck collar which is used to stabilise the cervical spine in a trauma patient when used in conjunction with 2 sand bags and tape (Triple Immobilisation).
They are sized by measuring the number of fingers from the clavicle to the angle of the mandible, and this is then compared to the measuring peg on the stiff neck collar.
Stoma Bags
A stoma bag is a prosthetic medical device that provides a means for the collection of waste from a surgically diverted bowel. Pouching systems are most commonly associated with colostomies, ileal conduits and ileostomies.
Surgical Chest Drain
Surgical Chest Drains (thoracostomy) are used as an emergency procedure. They differ from seldinger chest drains which can be inserted by trained physicians.
Sizing is measured in French (Ch) – smaller calibre drains used for pneumothorax, larger calibres needed for haemothorax, effusion and empyema.
Indications include: Pneumothorax, Malignant Pleural Effusion, Empyema, Traumatic pneumothorax or haemothorax, peri-operative.
ATLS guidelines should be followed in emergencies.
TEDS Stocking
This is a thromboembolic deterrent stocking which should be used in all patients undergoing surgery and those who are immobile to help prevent deep vein thromboses.
They are available in different sizes and are used in conjunction with low dose subcutaneous heparin. They are contraindicated in patients with arterial disease of the lower limb.
Tracheostomy
This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration.
One of the most common occasions you will see a tracheostomy is on a patient being ventilated on the intensive care unit.
A tracheostomy allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways. Tracheostomy can also be used in patients with upper airway obstruction or after laryngeal surgery.
Trucut Needle
This is a trucut biopsy needle which is used to take histological specimens from lesions, e.g. breast lumps or liver.
The procedure can be performed under local anaesthetic.
Urinary Catheter
Catheter sizes are measured in French (Ch). A 14Ch is a common starting point for catheters. The larger the Ch, the greater the diameter.
The three common types of urinary catheters include:
Foleys Catheter (centre) – short term up to 28 days catheter. Made usually of latex
Long-term Catheter (left) – up to 3 months made usually of silicone
Three-way catheter (right) – used in cases of haematuria for bladder washout and irrigation. Larger Ch required due to containing 3 lumens.
Urine Dip + Universal Sterile Container
Urine dipstick testing is very useful in the acute clinical environment and in primary care.
Key elements assessed in urine dipstick testing are blood (microscopic/macroscopic haematuria), protein (renal disease), nitrites (active infection), and leukocytes (inflammatory processes), glucose (diabetes), ketones (DKA), bilirubin and urobilinogen (haemolysis and liver pathology)
Positive tests for Nitrites and Leukocytes should be sent for urine MCS
Positive blood and protein should be sent for Urine Protein:Creatinine Ratio.
Urometer Drainage Bag
The urometer drainage bag allows monitoring of urine collection as it is designed with a clear graduation scheme. It reflects the accurate amount of urinary output per hour. It is used during surgery, postoperatively and to monitor fluid status.
Venturi Mask
Venturi masks are often using in COPD, where it is important not to over-oxygenate the patient. It delivers 24-60% oxygen. The flow rate varies depending on the colour. The correct flow rate to use with each colour it is shown on mask, along with the percentage of oxygen delivered.
Types:
–BLUE = 2-4L/min = 24% O2
–WHITE = 4-6L/min = 28% O2
–YELLOW = 8-10L/min = 35% O2
–RED = 10-12L/min = 40% O2
–GREEN = 12-15L/min = 60% O2
