Instruments and images Flashcards
Central venous catheter Indications
- Central venous pressure measurement - Administration of drugs: amiodarone - TPN
How is a central venous catheter used
Inserted using the seldinger technique under US guidance Sterile procedure Under LA Order CXR afterwards Common sites: int jugular vein, subclavian vein
Central venous catheter: complications
Immediate: pneumothorax, arrhythmia, malposition Early: infection, haematoma, occlusion Late: thrombosis, Phrenic nerve damage, sympathetic chain damage (corners)
Indication for central venous catheter vs PICC line vs Hickman line
CVC = short term use Hickman + PICC line = long term central access
Hickman line:
Tunneled under skin to enter IJV, and tip lies in the SVC
Tesio catheter: indication and features
Indication = haemodialysis Features = tunnelled subcutaneously Cuffs promote a tissue reaction –> creates a better seal Red limb: takes blood TO the machine Blue limb: takes dialysed blood BACK to patient
Tesio catheter: method
Sterile insertion under X-ray guidance
Tesio catheter: complications
Early: Pneumothorax Arrhythmia Bleeding Late: Infection Catheter occlusion Thrombosis
Blood bottles: Purple Yellow Grey - use? what does it contain?
Purple - contains EDTA to prevent clotting. use = FBC, X-match Yellow - contains activated gel. SERUM chemistry Grey - contains fluoride to inhibit glycolysis. Use = glucose
Endotracheal tube: indications
Definitive airway - long surgery: eg abdominal surgery - head injury –> reduced GCS
Endotracheal tube: features
Cuffed = prevents aspiration Long enough to sit below the vocal cords = definitive Blue line = radio-opaque
Endotracheal tube: method
- Anaesthetist - Pt sedated and muscle relaxant may be used - Laryngoscope aids direct vision - Tube is secured using tape Check position: symmetrical chest movements + auscultate for BS, CXR
ET tube: complications
Early: misplacement into oesophagus/bronchus TRAUMA - oropharyngeal/laryngeal Late: sore throat, tracheal stenosis
Guedel airway: indications
Non-definitive airway Used in its with lowered GCS to maintain a patient airway .e.g. during extubation
Guedell airway: method
Measure size: incisors –> angle of mandible Insert upside down, rotate once inside oral cavity
Guedell airway: complications
- Oropharyngeal trauma - Gagging –> vomiting –> aspiration
Ryles tube: indications
Draining the stomach, and NOT for feeding Drip + suck in obstruction
Ryles tube: features
Wider + stiffer than a feeding NGT Radio-opaque line –> to visualise on CXR
Ryles tube: insertion method
Sizing: tip of patient’s nose, down to epigastrium, going around the ear Lubricate the tip w gel Insert tube + ask pt to swallow sips of water when they feel is at back of throat Secure with tape Checking location: - Aspirate gastric contents + check pH<4 - CXR
Ryles tube: complciations
Nasal trauma Malposition Blockage
Feeding NG tube: indications?
Provides enteral nutrition: Reduced GCS/ITU Malnutrition Catabolic state: sepsis, burns, major surgery Dysphagia: stricture, stroke
Feeding NG tube: features and insertion?
Soft silicone + guide wire to aid insertion Sizing: tip of nose to epigastrium, going round the ear Lubricate tip w gel Insert via nostril + ask pt to sip water when they feel it at back of throat. Remove guide wire + secure with dressing Check location: CXR + aspiration of gastric contents <4
Foley urinary catheter: indications
- Urinary retention - BPH, neuropathic bladder - Monitor urine output in acutely unwell pt - Immobile
Foley catheter: features
2 ports: one for drainage of bladder, one for inflating balloon which keeps catheter in place Usually latex
Foley catheter: method
Obtain consent from patient ANTT - Clean the perineal area - Instillagel in the urethra + wait 2 mins - Insert catheter - Ensure urine is draining before inflating the balloon - Replace foreskin to prevent paraphimosis
Foley catheter: complications
Early: Paraphimosis Haematuria Urethral trauma Late: Infection Blockage
Initial Mx of hip fracture
ABC: resus Analgesia Assess neurovascular status of limb IMAGING - orthogonal views Prep for theatre: Anaesthetist - inform + book for theatre Bloods - FBC, clotting, G+S, Xmatch, U+E CXR DVT prophylaxis ECG
Risk factors for hip fracture
AGE + osteoporosis!! Steroids Early menopause EtOH + smoking Low BMI Hyperthyroidism Renal/liver failure Low calcium + Vit D intake/absorption Pre-existing bone disease (myeloma, RA)
Garden classification
For intracapsular NOF# 1. incomplete, undisplaced 2, complete, undisplaced 3. complete, partially displaced 4. complete, completely displaced
Surgical management of NOF#
Extra capsular = DHS or intramedullary Intracapsular: 1,2: DHS 3,4: THR (if fit), hemiarthroplasty if elderly
Stages of fracture healing
Reactive phase (- 48 hrs) - bleeding into fracture site + inflammation Reparative phase (2 days - 2 weeks) - Callus formation Remodelling phase (—–7 years) - Lamellar bone remodels to cope with mechanical forces applied to it “form follows function”
How to describe a fracture
Pt details Pattern: transverse/oblique/comminuted/spiral Anatomical location: shaft/epiphysis/metaphysis Intraarticular? Deformity: translation/angulation Soft tissues: open/closed?
Suture types
Absorbable vs non-absorbable Monofilament vs braided Natural vs synthetic
+ves and -ves of monofilament vs braided
Monofilament: + Less friction - Has more memory - More slip - Less tensile strength Braided: + Stronger + Easier to handle - less slip and less memory - increased risk of infection
2 Egs of absorbable sutures?
Monocryl = monofilament Vicryl = braided
Eg of non-absorbable suture? what is its construction and what is it used for
Prolene monofilament, used for vessel anastomosis _ skin wounds
causes of long QT interval
Heart: post MI, post cardiac arrest Clin chem: low Ca, K, Mg Congenital Drugs: amiodarone, citalopram
blood culture bottles: which colours for which bacteria?
Red: anaerobic Blue: aerobic take BLUE (aerobic) FIRST
Blood culture bottles: method
Take blood using ANTT. REPLACE NEEDLE w a clean one. Wipe top of bottles with EtOH Fill AEROBIC (blue) bottle first Fill in pt details + send to path lab
Indications for blood culture
pyrexia, suspected sepsis
Peripheral venous cannula - indications? method? complications?
Indication; admin of drugs, fluid, taking blood during insertion Method: into peripheral vein w ANTT Complications: - Malplacement - puncturing an artery, Extravasation - Haematoma - Blockage
PICC line - where is it inserted?
usually brachial vein
Port a Cath - indications? features?
Indications: long term chemo or Abx Centrally placed catheter Subcutaneous port made of rubber Accessed at 90 degrees w Huber point needle V low infection risk as breech is v small
When should blood cultures be taken compared to other blood tests
blood cultures FIRST
Laryngoscope: features?
Light source + handle Blade is detachable and comes in diff sizes, and straight vs curved
Complications of a laryngoscope
Oropharyngeal trauma Laryngeal trauma C-spine injury
Tracheostomy - indications? features?
Indications: - Definitive surgical airway - Emergency, in upper airway obstruction - Laryngeal surgery - Maxfax injuries Features: 1. Obturator - used to insert that trache, then removed 2. Cuff - to prevent aspiration 3. Flange - to secure to patient’s neck
Advantages of tracheostomy tube over ET tube
- no sedation - easier to maintain oral hygiene - less discomfort - less dead space –> reduced work of breathing
Complications of tracheostomy
Immediate: Haemorrhage, damage to oesophagus/rec laryngeal nerve, pneumothorax Early: Obstruction Displacement Surgical emphysema Late Tracheal stenosis Tracheomalacia TOF
LMA - indications
- Emergency, where ET tube cannot be placed 2. Non-definitive airway for short day case surgery
LMA - features
Inflatable cuff to seal over the larynx
LMA - method
- Cuff is deflated + lubricated - Open end inserted pointing down towards tongue - Sits over the larynx - Cuff is inflated + tube secured w tape - Position confirmed by equal chest expansion + breath sounds
LMA -complications
Aspiration - non definitive airway Dislodgement
Guedell airway - indications
Emergency setting where ET tube cannot be inserted Maintaining airway in pt w low GCS!!
Guedell - method
Initially inserted w open end pointing to roof of mouth, then twisted 180 Measurement - angle of mandible to incisors
Guedell - complications
- Oropharyngeal trauma - Gagging –> vomiting - Aspiration
Nasopharyngeal airway - indications
Maintaining an airway in low GCS
NP airway - method
diameter = little finger length = tragus of ear –> nostril Inserted into the nose w a ROTATIONAL action Safety pin at end prevents tube loss lol
NP airway - complications
Trauma to nasal mucosa –> epistaxis Intracranial placement (via cribriform plate in basal skull #)
NP airway - contraindications
Evidence of basal skull # - Racoon eyes - mastoid bruising - haemotympanum - CSF rhinorrhoea/otorrhoea
Max rate of O2 delivery through nasal prongs
4L
Non-rebreather mask: features
Enhances oxygen delivery, as long as pt can breathe unassisted Reservoir bag = 1.5L One way valve, prevents reinhalation of expired air
Indications for ventilation
-Respiratory failure that is not improving with less invasive airway management
Complications of ventilation
- Pneumothorax - Fluid retention - pneumonia - tracheal stenosis
Indications for parenteral nutrition
- Unable to swallow (oesophageal ca) - Prolonged obstruction/ileus - Severe malnutrition - severe Crohns
Delivery of parenteral nutrition
Must be delivered CENTRALLY as high osmolality –> toxic to vessels Short term - CVC Long term - PICC or Hickman
Monitoring in parenteral nutrition
Fluid balance + electrolytes inc Zn, Mg FBC, glucose, U+Es, LFTs
Complications of parenteral nutrition
Line related: infection, thrombosis, pneumothorax, arrhythmia Feed related: - electrolyte imbalance - villous atrophy of GIT - hyperglycaemia - vit and mineral deficiencies
Refeeding syndrome - pathophysiology? what is the main problem and what features does it cause
Starvation –> low insulin, low protein + fat metabolism and low intracellular phosphate Refeeding –> high insulin, rapid uptake of phosphate into cells Main problem = hypophosphatemia –> rhabdo, seizures, arrhythmia, shock
Chemistry in refeeding syndrome
LOW PHOSPHATE and low K and Mg
How to prevent a DVT
Pre-op: Stop OCP 4 weeks before VTE risk assessment Hydration Intra-op: Short length Minimal access Intermittent pneumatic compression boots Post-op: Analgesia –> mobilisation Hydration LMWH
Indications for Hartmann’s
Trauma, Burns
how much Na in 1L 0.9% saline?
154mM
Two types of open drains?
pemrose, tissue drain
Suture types- +ves and -ves
Monofilament vs braided Monofilament: + less friction + less infection - memory - slippy
Egs of diff sutures
Monocryl (monofilament + absorbable) Vicryl (braided + absorbable) Proline (non-absorbable)
Suture used for bowel anastomosis? For arterial anastomosis?
Bowel anastomosis = vicryl Arterial nastamosis = prolene
Name of retractor used for abdo surgery
Denver’s retractor - can be bent to a suitable shape
length of rigid sigmoidoscope vs proctoscope
Rigid sig = 25cm
length of rigid sigmoidoscope vs proctoscope
Rigid sig = 25cm Proctoscope = 13cm
Indications for a disposable proctoscope
Investigation of PR bleed (?haemorrhoids, lower rectal ca) Therapeutic: sclerotherapy, banding
Method of proctoscopy? complications
Pt in L lateral position, knees bent Perform DRE Lubricate + attach light source Insert
What is injected into haemorrhoids for sclerotherapy? how is it injected?
5% phenol in almond oil Inject 2mL above the dentate line
Name of syringe used for haemorrhoid sclerotherapy
Shouldered/Gabriel syringe
Indications/uses for rigid sigmoidoscope
? rectal cancer ? diverticular disease ? IBD can also take a biopsy!
Method for rigid sigmoidoscope
- L Lat position + DRE first - Lubricate the scope and insert - Remove obturator - Use light source + - INSUFFLATE w air
What gas is used to inflate the abdomen in laparoscopic surgery? why?
CO2 - cheap +inert
Intra-operatively, how is the integrity of an anastomosis checked?
Fill pelvic cavity w saline Insufflate rectum w air + look for bubbles
Indications for catheterisation
Diagnostic: measure urine output, sterile urine sample Therapeutic: relieve retention, immobility, bladder irrigation,
Urinary catheter - contraindications
Urethral trauma! - Urethral stricture - blood @ urethral meatus - Post-op urological pts
Causes and Mx of non-draining cathter
Blocked? - flush w 20mL saline or consider 3 way catheter Renal or pre-renal failure???
What is TWOc
Trial without catheter after acute urinary retention May be performed as a urology outpatient if retention again is likely
Indications for long term cathterisation
Chronic obstruction (BPH) Neurogenic bladder Complications of incontinence –> pt preference, palliative care
Indications for intermittent self cathterisation
Neurogenic bladder: DM, MS Chronic retention - an alternative to long term catheterisation
Indication for 3 way foley cathter
Irrigate bladder in pts @ risk of clot retention eg after TURP or in pts w haematuria
Suprapubic catheter- indications?
Urethral obstruction: BPH, rotate ca Urethral INJURY
Method of insertion of suprapubic catheter
US guided insertion under LA
Complications of suprapubic catheter
Haemorrhage Malignancy SEEDING Viscus perforation
Advantages and disadvantages of suprapubic cathter
+ves: Fewer infections, less stricture formation, more comfortable, maintains sexual function -ves: more complex serious complications: eg malignancy seeding
Contraindications for suprapubic catheter
Bladder carcinoma Undiagnosed suprapubic Previous lower abdo surgery
Mx of acute urinary retention
- Catheterise (3 way if clots) - Analgesia - hourly UO + replace - STAT GENTAMICIN COVER - (tamsulosin - reduces risk of recathetrisation after retention) - TOWC after 24-72 hours
2 different methods of JJ stent insertion
Percutaneously OR retrograde, via cystoscopic guidance
3 indications for chest drain
Pneumothorax Pleural effusion After thoracotomy or oesophagectomy
Safe triangle for chest drain
Lateral edge of pec major Anterior edge of Lat dorsi 5th ICS
How is incision made for chest drain insertion
Infiltrate area with 1cm incision w scalpel Blunt dissect with SPENCER WELLS FORCEPS Clear adhesions w finger
Indications for fracture plate
Internal fixation of fractures
How is a fracture plate used? how is it secured?
Internal fixation of a fracture Plate is aligned to the bone + screws fix the plate to the bone!
Complications of using a fracture plate
Infection Failure Malposition of remodelled fracture
Name of a hemiarthropalsty prosthesis? Indications? Feature?
Austin Moore Intracapsular NOF #, Garden 3/4 where pt is immobile Has fenestrated stem - promotes bone growth around it
Complications of hip replacement
Early: deep infection, dislocation, DVT Late: loosening (septic or aseptic) Failure –> stem # Revision - most replacements last 10-15 years
Cemented vs uncemented
Cement = acts as glue to attach the prosthesis to the existing bone Uncemented = promotes the new bone to grow around it. but longer recovery period
Indications for intramedullary nail
Internal fixation for long bone #s: tibia, femur, humerus
Principle behind a DYNAMIC hip screw
Allows collapse of the femoral head onto the neck –> increased loading of fracture site –> quicker union
How does fat embolism syndrome often arise? Key Fx?
Embolisation of bone marrow fat in circulation, often due to intramedullary nailing or THR/TKR Key features: Hypoxaemia Petechial rash CNS depression Pulmonary oedema
