Instruments Flashcards
Sutures
Indication, complications
Wound closure & approximation of tissue
Cause tissue foreign body reaction
Specific type chosen based on diameter, tissue strength, duration of closure
Absorbable suture types
Types, indication
Vicryl (polyfilament)
Monocryl, PDS (monofilament)
Also can have synthetic vs natural (catgut)
Used for: deep or rapid healing tissues e.g. bowel, biliary, urinary
Non-absorbable suture types
Types, indication
Monofilament - Nylon (Ethilon)
* Need 9 throws
* Percutaneous wound closure
Monofilament - Prolene
* Less likely to loosen
* Bowel, vascular anastomosis
Multifilament - Silk
Used for: permanent support & slower healing tissues, vascular anastomoses, tendon, fascia
Suture filament types
Monofilament = less trauma & tissue reaction, lower infection risk, prefrred for superficial wound closure
Braided (multifilament) = easier to handle, retain knots, increased infection risk (but can be coated in antibacterial substance to reduce)
How do absorbable sutures work?
Broken down by physiological processes of body e.g. enzymatic degradation, hydrolysis
Indications for ABG
New oxygen requirement
Identify acidosis / alkalosis
Identify resp failure
Identify any compensation
Identify poor perfusion (lactate)
Estimate of anaemia
Monitoring & Tx electrolyte disturbance - hyperK
Information given by VBG/ABG
pH
pO2, pCO2 - only useful in ABG
bicarbonate
Lactate
Hb (estimate)
Na+, K+
Glucose?
Order of blood bottle filling
Blue
Yellow
Purple
Pink
Grey
Blue blood bottle - components and indication
Buffered sodium citrate
Coagulation studies, INR, D-dimer
Yellow/gold blood bottle - components & indication
Silica particles and serum separating gel (SST)
U&E, LFTs
Immunology, microbiology, biochemistry, endocrinology, toxicology, oncology.
Purple blood bottle - component & indication
Contains EDTA
Haematology tests
Pink blood bottle - component and indication
EDTA
group and save, X match
Special requirement for pink blood bottle?
Patient information must be handwritten at bedside
(& should be double checked)
Grey blood bottle - components & indication
Sodium fluoride, Potassium o always
Glucose, lactate levels
Red blood bottle - components & indication
Silica particles
‘Sensitive tests’ - Toxicology, drug levels, Abs, hormones, bacterial and viral serology
Dark green blood bottle - components & indication
Sodium heparin
Ammonia, renin, aldosterone, insulin
Light green blood bottle - components & indication
Lithium heparin, plasma separator gel (PST)
Routine biochemistry
Rust top blood bottle - components & indication
Nothing?
Viral immunology
Blood culture bottle
Features, directions for use
Ideally >1 set taken from different sites at spaced intervals
Taken before giving Abx (unless delay)
Aseptic non touch technique
Taken before other blood samples
Minimise contamination of samples by air, commensals.
Blue vs purple blood culture bottle
Blue = Aerobic bacteria, fill first (if using vacutainer)
Purple = anaerobic
Indication for blood culture
Investigation of pyrexia
Suspected systemic sepsis
Indications for blood glucose monitoring kit?
Guide insulin dosing (T1 and some T2 DM)
Diabetic crises - DKA, HHS
Reduced GCS
Seizure
Indications for breast implant
Gender reassignment surgery
Reconstruction following mastectomy
Breast augmentation
Complications of breast implants
Rupture
Infection
Capsular contracture
Erosion through skin
Migration
Anaplastic large cell lymphoma - recent!
Indication for catgut suture
Stoma
Circumcision
How is catheter bag used
Attached to tubing that drains urine from bladder via urethra (urethral catheter) OR through small opening in abdomen (suprapubic catheter)
Collects urine
Urometer = bag + collection chamber, allows accurate recording of urine output
Central venous catheter
Indications
Central administration of medication (esp. irritants): vasopressors, inotropes, chemotherapy
Total parenteral nutrition
Access for extracorporeal circuit - renal replacement therapy
Monitoring - central venous pressure
Contraindications to central line insertion
Obstructed vein (clot)
Stenosis
Raised ICP
Severe coagulopathy
Resp failure with high FiO2
Contaminated, traumatised or burned site
Placement of central venous line?
Into SVC? via:
* Internal jugular vein
* Subclavian vein
Done under USS guidance
Complications of central line
Misplacement +/- Pneumothorax
Sepsis
Thrombosis
Surgical drains
Criteria for removal
Drainage stopped or < 25ml/day
If used for peri-operative bleeding: after 24-48 hrs
T- tube (CBD op): 6-10 days
Remove by 2cm/day to allow tract to heal
Uses of chest drain
Collect blood, fluid, pus from pleural space
- Pneumothorax
- pleural effusion
- traumatic haemopneumothorax (wide bore)
- empyema
- post surgical
Types of chest drainage
Passive drainage - sterile water filled to “prime level” submerges drainage tube, creates underwater seal + 1-way valve, positive expiratory pressure and gravity drain pleural space (must be kept below patient)
OR attach suction to top of chest drain bottle to create active closed drainage system
Clamping + suction should only be performed under senior supervision
CSF Manometer - purpose?
Identify opening pressure during LP - gives a measure of intracranial pressure (in cm H2O)
Abnormal CSF manometer result?
Normal = 10-18cm H2O lying on side or 20-30 sat up
Devers rectractor - use
Open abdominal surgery
Retract tissues to allow surgeon to visualise and operate
Rigid sigmoidoscopy - use
Inspection of (anus), rectum and lower sigmoid
Allow biopsies to be taken of rectal mucosa e.g. UC
Decompress volvulus
Tx haemorrhoids
Rigid sigmoidoscope - how does it work?
Explain + consent pt
Attach light source and air pumping device
Patient in left lateral position
DRE performed then sigmoidoscope inserted with lubrication (pointing towards umbilicus)
Obturator removed + air insufflated to optimise view
Visual inspection for pathology
Max insertion 15-20cm
How does standard drainage bag work?
Closed passive drainage system - gravity reliant
Uses for standard drainage bag?
NG tube
Abdominal drain (post surgery or ascites)
Endotracheal tube - what is it
Definitive airway
Tube inserted into trachea via oropharynx under direct visualisation
How is ET tube inserted?
Via oropharynx
Using laryngoscope and Eschmann Tracheal tube introducer (bougie)
Balloon inflated with air through side port (blue) - maintains position, protects from aspiration
Secured with tape
Tracheostomy benefits
Vs ET tube intubation
Reduced dead space
Improved oral hygiene
Reduced sedation
Allows pt to speak (fenestrated inner cannula or speaking valve)
Indications for intubation
Decreased LOC & loss of airway reflexes (GCS < 8)
Failure to oxygenate (T1RF)
Failure to ventilate (T2RF)
Failure to maintain patent airway - angioedena, upper airway obstruction, facial/airway trauma
Complications of intubation
Early:
* Failure ‘can’t intubate, can’t ventilate’
* Trauma
* Bleeding
* Cuff perforation
* Endobronchial intubation
Late
* Tracheal necrosis
* Tracheal stenosis
* Trache-oseophageal fistula (prolonged ventilation)
Tracheostomy tube
Definitive airway
Inserted below glottis (1-2cm inferior to cricoid cartilage) - surgical or percutaneous access
Indications:
* weaning of mechanical ventilation
* severe maxillofacial trauma
How to check position of ET tube?
Symmetrical rising of chest
Breath sounds bilaterally
No gurgling over epigastrium (suggests oesophageal intubation)
Alternatives: CXR, CO2 monitor (best), aspirate
Oropharyngeal airway
Indications, Directions for use, Complications
1st line airway adjunct
Sized by measuring incisor -> angle of mandible
Insrted into mouth ‘upside down’ and rotated within oral cavity (EXCEPT CHILDREN)
Risks: vomiting, aspiration (if gag reflex present)
Complications of ET tube placement
Inappropriate placing
Injury to surrounding structures - larynx
Pneumothorax
Atelectasis
Infection
Indications for stool sample
Suspected pathogen in gut
Bristol stool chart 5, 6, 7
Tests that can be done on stool sample
MC&S - 4 days for result
Rotavirus, adenovirus, norovirus - same day
Glutamine dehydrogenase (for C diff) and C diff toxin if positive
C. Diff ribotyping - 2 weeks
Microscopy for ova, cysts, parasites - 4 days
H. Pylori antigen - 1 week
Indications for feeding NG tube
Unsafe swallow e.g. stroke
Inadequate oral intake - Anorexia nervosa
Fluid giving set - uses
Administration of IV fluids, IV medication including antibiotics, blood products
Forceps - difference & indications?
Toothed aka dissecting / Ramsay forceps = skin only
Non toothed - once inside peritoneal cavity
Held in pincer grip
Fracture plate - use
In conjunction with screws
To internally fix a fracture of bone
Colloid - example, indication
Gelofusin(e) = artificial e.g.
Blood, albumin = natural e.g.
Raise plasma oncotic pressure, expand intravascular compartment
Sepsis, hypovolaemic shock
Crystalloid - example
Hartman’s, Plasmalyte
Crystalloid solution - indication
Normal daily fluid requirement of patient
Supplement additional losses
Initial fluid resus in advanced trauma and life support guidelines
Hemiarthroplasty - indications
Intracapsular fracture of neck of femur
Hickman line - what is it
Type of tunnelled central line
Has Dacron cuff = Abx infused cuff, stops infection tracking down line
Long term central venous catheter (months-yrs)
Hickman line - how is it inserted
Often into subclavian via subcutaneous tunnel
Remnant of line is tunnelled subcutaneously to reduce infection risk
Tesio line
Indications, features
2 x separate tunnelled catheters
Indication: haemodialysis (renal replacement therapy)
Port-a-Cath
Indications, features
Lies under skin
Must only only Huber, non-coring needles (part instead fo cutting)
Indications: chemotherapy?
VasCath
Indications, features
Similar to Tesio but 2 catheters are formed into 1
Indication: haemodialysis (renal replacement therapy)
Hickman line - indications
Long term parenteral nutrition
Long term IV antibiotics, chemotherapy
Regular vascular access, blood sampling
?Renal replacement therapy
Types of hip prosthesis
Hemiarthroplasty - single component
Total hip replacement - 2 components (femoral and acetabular)
Total hip replacement - components
Femoral stem
Femoral head
Polyethylene liner
Acetabular shell
Indications for total hip replacement
Elective: Severe osteoarthritis of hip
Emergency/acute: intracapsular NOF (hemi = comorbid, THR = healthier)
Complication of total hip replacement
DVT
Infection
Dislocation
Osteolysis, metal sensitivity, nerve injury, chronic pain
Histology pot - uses
Biopsy material, resected tumour etc.
Set in formalin for histological analysis
Intramedullary femoral nail - uses
Internal fixation of femoral shaft fracture
Intramedullary femoral nail - how is it used
Interlocking screws fix nail in place
Removed after 12-18 months
Instillagel - what is it
Local anaesthetic and lubricant sterile gel
Instillagel - indication
Insertion of male and female urinary catheter
Cannula sizes
24G - yellow / 26G violet = paediatrics
22G - blue
20G - pink
Both standard on ward
16G - grey, fluid resus and trauma
Laryngoscope - uses
Aid intubation
* Held in left hand
* Tip inserted into vallecula
* Light source turned on when fully extended
Also used to visualise larynx - diagnose vocal problems, strictures
Laryngoscope - types
Curved blade - Mackintosh
Straight blade - Miller
Complications of laryngoscope
Mild soft tissue injury
Laryngeal and pharyngeal scarring
Ulceration
Abscess formation
Esp. if by inexperienced user
Laryngeal mask / iGel
what is it, indications
Supraglottic airway adjunct/device
Bridge to ET intubation (cardiac arrest)
Elective short surgery with low aspiration risk
Rescue airway in failed ET intubation
Does NOT protect against aspiration
iGel - how does it work
Inserted via oropharynx (with number facing you when behind patient)
Cuff made from thermoplastic elastomer which shapes to patient perilaryngeal framework
Has separate lumen to allow passing of NG tube for gastric decompression
Can also be used as conduit to pass ET tube
iGel - sizing?
Weight based
Size 2 and 3 most common
Leg bags- what is it
Drainage / urine collection bag that is connected to urinary catheter and can be strapped to leg of patient
Leg bag - indication
Mobile patient with short term or long term indwelling urinary catheter
Mannitol - instructions for use
Use filter - crystals can form in ampoule
Mannitol - indications
Lower a raised ICP (in context of trauma not malignancy)
Increase urine output in patient with obstructive jaundice - prevent hepato renal syndrome
Diathermy - types
Monopolar - current flows between pen + dispersive electrode pad placed somewhere on patient
Bipolar - current flows between the two electrodes mounted on forceps, used where tissue can be grabbed from both sides
Diathermy - uses
In open or laparoscopic surgery:
- Coagulation - achieve haemostasis
- Dissect tissues
Self-inflatable bag-valve mask
Indications, flow rate
High levels of oxygen delivery (even at low-flow rate)
Cardiac arrest (prior to more definitive airway)
Nasal cannulae
Indications, flow rate
1st line oxygen therapy (mild hypoxia)
* long term O2 therapy in COPD
Carries max 4-5L/min (usually 1-3)
Delivers 22-44% FiO2
Venturi mask
Indications
Multiple valves of different colours allow controlled FiO2 delivery (FiO2 written on valve)
Risk of T2 respiratory failure + CO2 retention e.g. COPD
Oxygen delivery ladder of escalation
- Nasal cannula
- Face mask (and venturi)
- Non re-breathe mask
- High flow nasa lcannula
- NIV - BiPAP, CPAP
- Mechnical ventilation
Oxygen face mask
Indications, flow rate
O2 delivery in moderate hypoxia
Up to 10L/min
25-60% FiO2
When combined with bag + valve = non rebreathe mask
* 1st line acutely unwell pt
* up to 15L/min
* 80-85% FiO2
Nasal cannulae - complications
Nasal sores, ulceration
Necrosis
Epistaxis
Nasal speculum - uses
Open and expand nasal cavity
E.g. to visualise source of epistaxis
Nasopharyngeal airway
Indications, sizing
Pts with decreased LOC but intact gag reflex
Diameter of tube sized against patients little finger (distal phalanx) OR by height (6 for female, 7 for male)
Nasopharyngeal tube - how to insert
Inserted horizontally into nostril using rotational action
(Safety pin placed in end of tube to prevent inhalation)
Nasopharyngeal tube - CONTRAINDICATIONS
Basal skull fracture
Facial trauma
Disruption of mid face, nasopharyngeal or roof of mouth
Transphenoidal or similar access surgery
Can result in cribiform insertion
Other complications: epistaxis, ulceration
Nebuliser - components
Face mask
Medicine cup
Plastic tubing
Compressor
Nebuliser - uses
Administration of bronchodilators for respiratory conditions e.g. salbutamol in asthma
Needle holder - what is it/use
Specific type of hinged forcep
Designed to hold suture needles between teeth, used for passing needles through tissue when suturing
General Presenting Structure
This is a ….[name]
It has/There are….[ description of features]
It is used for … [indications]
Common complications include ….
Cannula
Indications, Directions for use
1st line for IV access for administering medication, fluids, blood products.
Can also be used to take blood (during insertion only
Aseptic non touch technique
Colour coded by gauge (diameter)
Cannula sizing
Principle = use smallest size needed
- Orange: 14G - trauma, rapid transfusion, surgery
- Grey: 16G - trauma, rapid resus, rapid transfusion
- Green 18G - trauma, rapid resus, rapid transfusion
- Pink: 20G - most infusions, routine transfusion
- Blue: 22G - most infusions, neonate/paeds, elderly
- Yellow: 24G - as above + neonate blood transfusions
- Purple: 26G - neonate/paeds
Cannula - complications
Extravasation
Haematoma
Phlebitis
Thrombosis
Systemic infection
Extension set/line
Single or multi lumen
Connects to cannula for administration of fluids, medications
Reduces risk of inadvertent cannula removal?
Directions for use: flushed & cleaned regularly, may need to be primed before initital connection to cannula?
Central venous catheter
Directions for use
Inserted into (?SVC via) internal jugular, subclavian or femoral vein
Single or triple lumen
Short term use (days-weeks)
Seldinger technique
Components of Seldinger (central line) kit
3-5 lumen cannula
Introducer needle
Guide wire
Dilator
Scalpel
Types of central venous line/catheter
Central venous catheter
Peripherally inserted central catheter
Hickmann
Tesio
Vascath
Port-a-Cath
Seldinger technique
Applications
central venous catheter
arterial access (angiography)
intra-abdominal/biliary/ureteric drainge
PEG insertion
Pacemaker lead/ICD insertion
Seldinger technique
Process & applications
- Hollow needle inserted
- J-tip guidewire advanced
- (?Position confirmed using USS)
- Needle removed, leaving guidewire
- Sheath advanced over guidewire
- Sheath advanced to skin entry
- Guidewire & dilator removed leaving sheath/catheter
Peripherally inserted central catheter (PICC)
Features, Directions for use
Inserted into basilic/cephalic veins, tip sits within Superior vena Cava (seen at cavo-atrial junction on CXR).
Medium term use (weeks - months)
Indications for PICC
IV administration of medication, antibiotics, chemotherapy
Poor peripheral access
Complications of central access
Central venosu catheter, Hickmna/Tesio, PICC
Immediate: haemorrhage, pneumothorax, arterial puncture, arrythmia, cardiac tamponade, air embolism.
Delayed: venous stasis, thrombosis, erosion of vessel, line fracture, catheter colonisation & line-related sepsis.
Chest drain
Directions for use
Inserted into triangle of safety:
* anterior border of latissimus dorsi
* lateral border of pectoralis major
* line superior to the horizontal level of the nipple / 5th ICS
* apex below the axilla
Inserted just superior to rib to avoid neurovascular bundle
Position confirmed with CXR
Complications of chest drain
Insertion related:
* Damage to nearby structures - intercostal artery, solid organ
* Subcutaneous emphysema
* Pneumothorax
Position related:
* Obstruction, kinking, dislodgement
* Re-expansion pulmonary oedema
Infection: wound, pneumonia, empyema
Chest drain bottle movements
Swinging - movement of water column with respiratory cycle (up = inspiration, down = expiration)
Bubbling = air leaving pleural cavity, will stop when all air expelled
Surgical drains
Tubes inserted into surgical field to allow decompression of fluid/air
Indications:
* Drainge of potential space post-op
* Removal of harmful fluid e.g. blood, pus, bile
* Detection of bleeding/leakage e.g. post-anastomosis
Types of surgical drains
Open e.g. rubber, corrugates - connect to external environment, used in superficial wounds, increase risk of infection
Closed = connect via tubing to drain bottle
Active = maintained under negative presusure, improve wound closure
Passive = gravity, preffered in abdomen (less risk of visceral perforation)
Complications of surgical drains
Ascending infection - more with open or passive system
Foreign body reaction - fibrosis, granuloma
Migration
Obstruction, kinking
Fistulation
Nasogastric feeding tube
Features, Directions for use
Narrow bore (< 9 Fr)
Exaplain + consent pt
Lubricated and inserted via nostril whilst patient swallows
Inserted with guidewire
Position confirmed with pH of aspirate (< 4.5 but trust dependent) and/or CXR
Indications for NG tube
Short/medium term feeding - max 4-6 weeks in pts with functional GI tract
Administration of drugs/contrast in unsafe swallow
Ryles tube
Wide bore (16-18 Fr)
Thicker walls prevent tube collapse during aspiration
No guidewire
Indications for Ryles tube
Gastric decompression
* bowel obstruction
* ileus
* post-surgery
* ?aspirating toxins
CXR criteria for NG tube placement
- Follows oeseophgagus/avoids contours of bronchi?
- Bisects carina?
- Cross diaphragm in midline?
- Tip visible below let hemi diaphragm?
Contrindications to NG tube
Basal skull fracture
Nasal injury
UGI stricture
Complications of NG tube
Pulmonary
* Aspiration pneumonia - feeding through incorrectly sited tube
* Pneumothorax
GI
* Malposition in GI tract
* Obstruction, kinking, knotting
* Reflux oesophagitis, gastritis
* Visceral perforation - RARE
Post-pyloric feeding
Directions for use, indications
Tube passed through pylorus and rests in jejunum
Endoscopic or fluoroscopic placement + confirmation
Indications:
* Gastroparesis - diabetes, critical illness
* Outlet obstruction - peptic ulcer disease, malignancy
* Recurrent aspiration
* Pancreatitis
Urinary catheter
Directions for use, features
Aseptic non touch technqiue
Inserted via urethra into bladder
Balloon inflated with sterile water to secure
Drainage of urine
14-16 typical size
Latex (yellow) or silicone (transparent)
Silicone»_space; if long term
Curved tip (Coude) also available, facilitates insertion past enlarged prostate
Indications for urinary catheter
Urinary retention
Measurement of urine output (acute illness)
Abdominal/pelvic surgery
Neurogenic bladder - intermittent
Immobility
EOL care
Urinary incontinence
Sacral/perineal ulceration
3-way urinary catheter
Directions for use, indications
Larger diameter (18 - 22)
3rd lumen allows bladder irrigation, prevents clot retention
Indications:
Visible haematuria + clots
Post bladder/prostate surgery
Complications of urinary catheterisation
Immediate/early
* Urethral trauma
* Allergic reaction to material
* Balloon rupture
* Obstruction, bypass/leakage
* Bladder perforation - RARE
Delayed
* Bacteriuria/UTI
* Pyelonephritis
* Urethral stricture
* Bladder stones
Proctoscope
Indications, directions for use
Inspect anus & lower rectum
Inserted as per rigid sigmoidoscope - L lateral position, DRE beforehand
- biopsies?
- polypectomy?
- combined with sclerotherapy + banding (haemorrhoids Rx)
Stoma bag
Features, indication, complication
Sticks to abdominal wall & collects flatus, faeces or urine.
May have filter to release wind + prevent inflation
May have deodorising component
Adhesive can cause irritation ‘stomal dermatitis’
Scalpel
Formed of blade + handle
Handle = reusable or disposable
Blades = single use stainless steel, numbered by shape
* 10 blade = ‘traditional’, large cutting curve, skin incision
* 11 = pointed apex, puncturing movement
* 15 = smaller cutting surface, delicate
Laparoscopic trocar
Create entry ports in laparoscopic procedures
Inserted via Veress needle, Hasson technique etc.
Once 1st port places + pneumoperitoneum established, further post inserted under direct vision
Risk = perforation/damage to viscera (1st port = highest risk as inserted ‘blind’)
Pneumoperitoneum (in surgery)
Achieved with CO2
Inert, soluble in blood & tissues, rapidly cleared by expiration
TED stocking
Graduated compression (maximum distally)
DVT prophylaxis, used in:
* patients undergoing surgery
* immobile pts
* can be combined with LMWH
Contraindications to TEDs
Severe pepheral vascular disease
Severe skin breakdown - ulcers, infection
Intermittent pneumatic compression
Features, indications
Inflatable sleeves, typically wrapped around calves
Inflated one side at a time
Reduce risk of venous stasis & VTE
* intra-operatively?
* post abdo-ortho surgery
* post-stroke
Contraindications to Intermittent Pneumatic compression
Severe peripheral vascular disease or skin breakdown (ulcers, infection)
Stiff Cervical Collar
Stabilising cervical spine in trauma patient
Forms part of triple immobilisation: collar, x2 sand bags, tape
Sized by measuring no. fingers from clavicle- angle of mandible (compare this with peasuring peg on collar)
Trucut biopsy needle
Take specimens from lesions e.g. breast lump, liver for histological analysis
Can be performed under local anaesthetic
Tesio line
2 x separate tunnelled catheters
Indication: haemodialysis (renal replacement therapy)
Types of spinal needle
Traumatic
* ‘cutting’ needle
* Higher risk of post-LP headache
Atraumatic
* ‘pencil point’ needle
* allow blunt dissection of anatomy not cutting)
Use of urine dip
Acute clinical or primary care setting
Identification of:
Micro-macroscopic haematuria
Proteinuria
Nitrites
Leucocytes
Glucose
Ketones
Bilirubin, urobilinogen
Specimen swabs
Types, indication
Sterile swabs
MRSA screening - nasopharyngeal, rectal
Bluetop Transwab Amies - aerobes, anaerobes, fastidious organisms
Epidural vs spinral anaesthesia
Epi:
* high volume
* slow onset (25-30m)
* no significant NM block (can move legs)
* continuous infusion
* Uses: C-section, labour
Spinal:
- low volume
- fast onset (< 5 mins)
- significant NM block
- single dose
- given only at L3/4
- Uses: knee replacement, abdo surg if resp disease?
