Instruments Mushkies Flashcards
1
Q
5 types of vascular access?
A
- Peripheral venous cannula
- Triple lumen central venous catheter
- PICC line
- Hickman line
- Tessio catheter
- Port-a-cath
2
Q
Peripheral venous cannula indication?
A
Peripheral administration of fluid and drugs
3
Q
Types of peripheral venous catheters?
A
Colour, Gauge, Flow rate (ml/min)
- 24G = yellow = 15 ml/min
- 22G = blue = 30ml/min
- 20G = pink = 60ml/min
- 18G = green = 90ml/min
- 16G = grey = 230ml/min
- 14G = brown = 270ml/min
4
Q
Poiseuille’s law?
A
Flow rate is proportional to r^4, and inversely proportional to length
5
Q
Method of peripheral venous catheter insertion?
A
Inserted into a peripheral vein under ANTT
6
Q
Complications of peripheral venous catheter insertion?
A
- Haematoma
- Malplacement
- Blockage
- Superficial thrombophlebitis
7
Q
Triple lumen central venous catheter indication?
A
- CVP measurement = fluid balance
- Drugs requiring central administration = amiodarone, mannitol
- TPN
8
Q
Method of central venous catheter insertion?
A
- Inserted using seldinger technique under US into internal jugular/subclavian/femoral veins
- Trendelenberg position, sterile, under LA, use US guidance, order CXR afterwards
9
Q
Complications of central venous catheter insertion?
A
- Immediate = pneumothorax, arrhythmia, malposition into artery
- Early = haematoma, infection, catheter occlusion
- Late = thrombosis, sympathetic chain (Horners), phrenic nerve damage (hiccough, weak diaphragm)
10
Q
4 procedures using Seldinger technique?
A
- Angiography
- Chest drain insertion
- PEG
4 Triple lumen central venous catheter
11
Q
PICC line?
A
Peripherally inserted central catheter
12
Q
PICC line indication?
A
Long term central access
- Abx
- Chemo
- TPN
13
Q
PICC line insertion method?
A
- Inserted into a peripheral vein e.g. cephalic
- Advanced until the tip sits in the SVC
- X-ray to confirm position
14
Q
PICC line insertion complications?
A
- Early = arrhythmias, bleeding
2. Late = thrombosis, catheter occlusion, infection
15
Q
Hickman line indications?
A
Long term central access
- Abx
- Chemo
- TPN
- Dialysis
16
Q
Hickman line insertion method?
A
Tunnelled under skin to enter IJV and lay in SVC
17
Q
Hickman line insertion complications?
A
- Early = arrhythmias, bleeding, pneumothorax
2. Late = thrombosis, catheter occlusion, infection
18
Q
Tesio line indication?
A
Haemodialysis
19
Q
Features and insertion method of Tesio catheter?
A
- Tunnelled subcutaneously, sterile insertion under X-ray guidance
- Cuffs promote tissue reaction –> better seal
- Arterial lead takes blood to machine
- Venous limb takes dialysed blood back to pt
- Arterial limb sits more proximally to prevent recirculation
20
Q
Tesio line insertion complications?
A
- Early = pneumothorax, arrhythmia, bleeding
2. Late = thrombosis, catheter occlusion, infection
21
Q
Port-a-cath indications?
A
Long therm chemotherapy or antibiotics
22
Q
Port-a-cath insertio method and features?
A
- Centrally placed catheter
- Subcutaneous port made of self-sealing silicone rubber
- Accessed with 90 degrees Huber point needle
- Very low infection risk as skin breech is very small
- Inserted into IJV, tip sits in the SVC/RA
23
Q
Blood culture bottle colours?
A
- Red = anaerobic culture medium
2. Blue = aerobic culture medium
24
Q
Method of taking blood cultures?
A
- ANTT
- Replace needle with clean one
- Wipe top of bottles with alcohol
- Fill anaerobic bottle first
- Fill in pt details and send to path lab
25
Vacutainer colours?
PYR GBGB
1. Purple
2. Yellow
3. Red
4. Green
5. Blue
6. Grey
7. Black
26
Purple vacutainer contains and use?
1. Contains = EDTA, prevents clotting and keeps cells alive
| 2. Use = FBC, CD4, cross match
27
Yellow vacutainer contains and use?
1. Contains = Activated gel, promotes clotting, gel facilitates easy separation of serum and red cells
2. Use = U&E (serum chemistries), enzymes
28
Red vacutainer contains and use?
1. Contains = Nothing, a 'clotted sample'
| 2. Use = Immunology, Abs, Ig, protein electrophoresis
29
Green vacutainer contains and use?
1. Contains = Li heparin, anticoagulant
| 2. Use = Plasma chemistries, enzymes
30
Blue vacutainer contains and use?
1. Contains = Citrate, chelates Ca, prevents clotting
| 2. Use = coagulation
31
Grey vacutainer contains and use?
1. Contains = fluoride (inhibits glycolysis), oxalate (anticoauglant)
2. Use = Glucose
32
Black vacutainer contains and use?
1. Contains = citrate, anticoagulant
2. Use = ESR
3. Special = need precise blood volume
33
Order of draw?
1. Blood cultures
2. Blue
3. Yellow
4. Green
5. Purple
6. Grey
34
ET tube indication?
To acquire a definitive airway in elective or emergency situations e.g. abdominal surgery or head injury
35
Features of an ET tube?
1. Cuffed = adults, secured tube and prevents aspiration
2. Uncuffed = children, avoid damaging the larynx
3. Size = Female (7.5), Male (8.5)
4. Double lumen = allow single lung ventilation, used in thoracic surgery
5. Radio-opaque line = blue
36
ET tube insertion method?
1. Pt is pre-oxygenated, sedated, and a muscle relaxant may be used
2. Inserted into the trachea under direct vision using a laryngoscope
3. Cricoid pressure may reduce risk of aspiration
4. Bougi may be used for difficult airways = smaller, anterior curvature, can feel tracheal rings with tip
5. Position confirmed and tube secured with tape
37
ET tube how to check position?
1. Check for symmetrical chest movements
2. Listen over epigastrium for gurgling
3. Listen over each lung for air entry
4. Use CO2 monitor
5. CXR = just above carina
38
ET tube complications?
1. Early
| 2. Late
39
Early ET tube complications?
1. Oropharyngeal trauma
2. Laryngeal trauma
3. C-spine injury e.g. w/ AA instability
4. Oesophageal intubation
5. Bronchial intubation
40
Late ET tube complications?
1. Sore throat
2. Tracheal stenosis
3. Difficult wean
41
Definitive airway defn?
Airway which is protected from aspiration
42
Types of definitive airway?
1. Orotracheal or nasotracheal
| 2. Surgical = tracheostomy, cricothyroidotomy
43
Macintosh laryngoscope indication?
ET intubation
44
Macintosh laryngoscope features?
1. Handle and light source
| 2. Removable blade, comes in different sizes, Macintosh (curved, preferred), and Miller (straight)
45
Macintosh laryngoscope method?
1. Pt sedated and muscle relaxed
2. Inserted with left hand, tongue displaced laterally
3. Tip inserted into epiglotic vallecula
4. Light source allows direct vision of vocal cords for intubation
46
Complications of macintosh laryngoscope?
1. Oropharyngeal trauma
2. Laryngeal trauma
3. C-spine injury e.g. with atlanto-axial instability
47
Temporary tracheostomy tube indications?
Definitive surgical airway
1. Acutely = maxillofacial injuries
2. Electively = ITU pts with prolonged ventilation
48
Features of temporary tracheostomy tube?
1. Obturator
2. Cuff to prevent aspiration
3. Flange to secure to pts neck
4. Insufflation port
49
Temporary tracheostomy tube insertion method?
1. Transverse incision 1cm above sternal notch
2. Dissect throughout fascial planes and retract anterior jugular veins and strap muscles
3. Divide thyroid isthmus
4. Stoma fashioned between 2nd and 4th tracheal rings by removing anterior portion of tracheal ring
5. Insert trachy with obturator
6. Secure with tapes
50
Advantages of temporary trache tube over ET tube?
1. Easier to wean pts
2. No need for sedation
3. Reduced discomfort
4. Easier to maintain oral and bronchial hygeine
5. Reduced risk of glottis trauma
6. Less dead space so reduces work of breathing
51
Complications of temporary tracheostomy tube?
1. Immediate
2. Early
3. Lat
52
Temporary trache tube immediate complications?
1. Haemorrhage
2. Pneumothorax
3. Damage = oesophagus, RLN
53
Temporary trache tube early complications?
1. Tracheal erosion
2. Tube displacement
3. Tube obstruction
4. Surgical emphysema
5. Aspiration pneumonia
54
Temporary trache tube late complications?
1. Tracheomalacia
2. TOF
3. Tracheal stenosis
55
LMA indications?
1. Non-definitive airway used in short day-case surgery where a pt doesnt require intubation
2. May also be used in emergency if not able to insert ET tube
56
LMA features?
Inflatable cuff to create a seal over the larynx
57
LMA insertion method?
1. Cuff deflated and lubricated with aquagel
2. Inserted with open end pointing down towards the tongue
3. Sits in orifice over larynx
4. Cuff inflated and tube secured with tape
58
LMA complications?
1. Dislodgement
2. Leak
3. Pressure necrosis in airway
4. Aspiration = non-definitive airway
59
Oropharyngeal/Guedel airway indications?
Airway adjunct used in pts with impaired level of consciousness ut maintain patent airway, e.g. during extubation
60
Oropharyngeal airway insertion method?
1. Sized from incisors to angle of mandible
| 2. Insert upside down and rotated once in the caivty
61
Oropharyngeal airway complications?
1. Oropharyngeal trauma
| 2. Gagging --> vomiting
62
Nasopharyngeal airway indicaations?
Airway adjunct used in pts with impaired level of consciousness ut maintain a patent airway
63
Nasopharyngeal airway insertion method?
1. Sized according to diameter of pts little finger
2. Inserted into nasopharynx using a rotational action
3. Safety pin and flared ends prevents the tube becoming irretrievable
64
Nasopharyngeal airway complications?
1. Bleeding = trauma to nasal mucosa
| 2. Intracranial placement
65
Nasopharyngeal airway contrainidications?
Facial injury or evidence of basal skull fracture?
66
Evidence of basal skull fracture?
1. Racoon eyes
2. Battle's sign = mastoid bruising
3. Haemotympanum
4. CSF rhinorrhoea or otorrhoea
67
Types of oxygenation?
1. Nasal prongs
2. Simple face mask
3. Non-rebreathable Hudson mask
4. Venturi mask
5. CPAP
68
Nasal prongs fx?
1-4L/min = 24-40% O2
69
Simple face mask fx?
Variable O2 concentration depending on O2 flow rate
70
Non-rebreathing Hudson mask fx?
1. Reservoir bag allows delivery of high concentrations of O2
2. 60-90% at 10-15L
71
Venturi mask fx?
1. Uses Bernoulli principle = increased speed of flow --> reduced pressure
2. Provides precise O2 concentration at high flow rates
3. Yellow = 5%
4. White = 8%
5. Blue = 24%
6. Red = 40%
7. Green = 60%
72
CPAP fx?
1. Tight fitting mask connected to reservoir or high O2 flow, allowing FIO2 of around 1
2. Positive pressure is applied continuously to the pts airway
3. Usually has little effect on PaCO2
73
Advantages of CPAP?
1. Recruitment of collapsed lung units
2. Reduced shunt --> Increased PaO2
3. Increased lung volume --> improved compliance --> reduced work of breathing
74
Types of ventilation?
1. Non-invasive = CPAP or BiPAP
| 2. Invasive = ET or tracheostomy
75
Indications for ventilation?
1. Resp failure refractive to less invasive Rx
2. At risk airway
3. Elective post-op ventilation
4. Physiological control e.g. hyperventilation in raised ICP
76
Complications of ventilation?
1. CVS compromise
2. Pneumothorax
3. Fluid retention
4. VILI
5. VAP
6. Complications of artificial airway e.g. tracheal stenosis
77
VILI?
Ventilator induced Lung Injury
78
VAP?
Ventilated associated Pneumonia
79
Ryles tube indications?
1. Draining the stomach
2. Bowel obstruction
3. Persistant vomiting e.g. pancreatitis
80
Features of Ryles Tube?
1. Wide bore
2. Stiff
3. Radio-opaque line
4. Metal tip
81
Ryles tube metal tip?
1. Acts as lead point to facilitate advancement of NHT
2. Weighs down NGT in the stomach
3. Radio-opaque on XR, aiding visualisation
82
Ryles tube insertion method?
1. Size tube by measuring from tip of pts nose to epigastrium, going around the ear
2. Gain consent and explain the procedure
3. Lubricate the tip with aquagel
4. Insert the tube and ask pt to swallow with water when they feel it at the back of their throat
5. Secure with tape when position confirmed
83
How to check location of ryles tube/feeding NG tube?
1. Aspirate gastric contents and check pH (<4)
2. Insufflate air and auscultate for bubbling (best to avoid in bowel obstruction)
3. CXR = tip below diaphragm
84
Complications of ryles tube?
1. Nasal trauma
2. Blockage
3. Malposition = airway, cranium
85
C/I of ryles tube or feeding NG tube?
Any suspicion of basal skull fracture
86
Feeding NG tube indications?
Provide enteral nutrition
1. Catabolic = sepsis, burns, major surgery
2. Coma/ITU
3. Malnutrition
4. Long term feeding
5. Dysphagia = stricture, stroke
87
Features of feeding NG tube?
1. Fine bore
2. Soft silicone
3. Radio-opaque guide wire ut stiffen tube and aid insertion
88
Feeding NG tube insertion method?
1. Size tube by measuring from tip of pts nose to epigastrium, going around the ear
2. Gain consent and explain the procedure
3. Lubricate the tip with aquagel
4. Insert the tube and ask pt to swallow with water when they feel it at the back of their throat
5. Remove guidewire and secure with tape when position confirmed
89
Complications of NG tube
1. NGT = nasal trauma, malposition, bloackage
| 2. Feeding = refeeding syndrome, e- imbalance, feed intolerance --> diarrhoea
90
Mx of refeeding syndrome?
1. Identify at risk pts in advance
2. Parenteral and oral phosphate supplementation
3. Manage complications
91
Daily requirement fluid regimens?
1. 3L dex-sal with 20mM K+ in each bag
| 2. 1L NS + 2L dex-sal with 20mM K+ in each bag
92
Surgical drain indications?
1. Prophylactic = prevent fluid accumulation
| 2. Therapeutic = drainage of established collections, drain a viscus e.g. bladder, collect blood for autotransfusion
93
Types of surgical drains?
1. Open or closed
| 2. Active or passive
94
Open surgical drain?
1. Fluid collects into dressing or stoma bag
| 2. E.g. corrugated rubber or plastic sheets
95
Closed surgical drain?
1. Tube attached to ao container
| 2. E.g. Chest drains, Robinson or Redivac
96
Active drains?
Driven by suction e.g. Redivac drain
97
Passive drains?
No suction, driven by pressure differential e.g. Robinson drain
98
Removal of surgical drains?
1. Remove once drainage stopped or <25ml/d
2. Perioperative bleeding and haematoma 24-48hrs
3. Intestinal anastomosis >5d
4. T-tube = 6-10 days (T-tube cholangiogram first to ensure distal patency of CBD)
5. Shortening = removal of drain by 2cm/d to allow tract to heal gradually
99
Complications of surgical drain?
1. Infection
2. Damage may be caused by mechanical pressure or suction
3. May limit pt mobility
100
Robinson drain type and use?
1. Type = Closed, passive
| 2. Use = abdominal surgery
101
Redivac drain type and use?
1. Type = Closed, active
| 2. Use = breast surgery (prevent seroma or haematoma), thyroid surgery (risk of haematoma)
102
Bile bag type and use?
1. Type = Closed, passive
| 2. Use = NGT, T-tube
103
Pemrose drain type and use?
1. Type = Open, passive
| 2. Use = abdominal surgery
104
Tissue drain type and use?
1. Type = Open, passive
| 2. Use = large cavities
105
5 different drains?
1. Robinson
2. Redivac
3. Bile bag
4. Pemrose drain
5. Tissue drain
106
Suture types?
1. Monofilament
| 2. Braided
107
Monofilament suture advantages?
Less risk of infection, less friction in tissues
108
Monofilament suture disadvantages?
1. Harder to handle (stiff and has more memory)
2. Knots may slip
3. Less tensile strength
109
Braided suture advantages?
1. Easier to handle: less memory
2. Knots may slip
3. Greater tensile strength
110
Braided suture disadvantage?
Increased risk of infection, increased friction on tissues
111
Types of suture?
1. Synthetic or Natural
2. Absorbable or non-absorbable
3. Monofilament or braided
112
Natural suture types?
1. Absorbable = catgut or chromic
| 2. Non-absorbable = silk (braided suture that may be used to secure drains)
113
Synthetic suture types?
1. Absorbable = monocryl, vicryl, PDS
| 2. Non-Absorbable = polypropylene, nylon, steel
114
Suture removal time from face and neck?
3-5 days
115
Suture removal time from scalp?
5-7 days
116
Suture removal time from trunk?
10 days
117
Suture removal time from arms?
7 days
118
Suture removal time from legs?
10-14 days
119
Types of needles?
1. Straight = hand-held, for skin closure
| 2. Curved = require needle-driver
120
Needle diameters?
1. Fine = GI and vascular surgery
2. Medium = general closure
3. Heavy = hernia repair
121
Blunt tip needle used for?
Abdominal wall closure
122
J-shaped needle used for?
Abdominal wall closure
123
Dever's retractor indication?
Surgical retractor used in open abdominal surgery to retract viscera and increase the field of view
124
Dever's retractor method?
1. Curved end inserted into abdomen and placed carefully to retract the viscera
2. Can be bent to a suitable shape
125
Dever's retractor complications?
Damage to the skin and internal structures
126
Self-retaining retractor indications?
Used to retract a surgical incision and retain the incision open, e.g. in hernia repair or appendicectomy
127
Complications of self retraining retractors?
Compression of nerves of vessels
128
Needle holders indication?
Forceps designed to hold the needle, allowing the surgeon to suture accurately
129
Disposable proctoscope indication?
1. Ix and Mx of pts with perianal pathology e.g. haemorrhoids, low rectal Ca
2. Examination of the anal canal and lower rectum +/- biopsy
3. Therapeutic = banding, sclerotherapy
130
Features of disposable proctoscope?
1. Obturator to aid insertion
| 2. Attachment for light source
131
Complications of disposable proctoscope?
Haemorrhage and perforation
132
Shouldered/Gabriel syringe indication?
1. Injection of haemorrhoids with 5% phenol in almond oil (sclerosant)
2. 2ml of phenol is injected above the dentate line: insensate
133
Complications of shouldered/Gabriel syringe?
1. Immediate = pain if injected below dentate line, Damage to nearby structures, Primary haemorrhage
2. Late = Prostatitis, inmpotence
134
Disposable rigid sigmoidoscope indications?
1. Allows endoscopic examination of the rectum and recto-sigmoid junction with possible biopsy, and can be used in the outpatient or inpatient setting
2. Investigation of: rectal bleeding, colonic neoplasia, IBD
135
Features of disposable rigid sigmoidoscope?
Graduated plastic tube with an obturator to aid insertion
136
Complications of disposable rigid sigmoidoscope?
1. Perforation = mechanical (pushing against bowel wall), pneumatic (over-inflation)
2. Bleeding
137
Laparoscopic port indications?
Access the abdomen during laparoscopic surgery e.g. lap chole
138
Features of laparoscopic port?
1. Trocar +/- sharp blades
2. CO2 insufflation port
3. Instrument port with rubber flanges
139
Where is the laparoscope usually inserted?
Umbilicus
140
Circular bowel stapler indications?
1. Rectal anastomosis
2. Gastrectomy
3. Haemorrhoids
4. Rectal prolapse
141
Features of circular bowel stapler?
1. Anvil sutured into proximal limb with purse string suture
| 2. Anvil fits into stapler and provides counterpoint for staple insertion
142
Complications of circular bowel stapler?
Anastomotic leak
143
How to check integrity of an anastomosis?
1. Intra-operative = fell pelvic cavity with saline, insufflate rectum with air and look for bubbles in the saline
2. Post-operative = water-soluble contrast enema
144
Catheterisation indications?
1. Diagnostic
| 2. Therapeutic
145
Diagnostic catheter indications?
1. Measure urine output
2. Sterile urine sample
3. Renal tract imaging
146
Therapeutic catheter indications?
1. Urinary retention
2. Immobile pts
3. Bladder irrigation
4. Intermittent decompression of neuropathic bladder
147
Foley catheter features?
1. One port for drainage and one to fill the distal balloon with sterile water
2. Distal balloon sits in the bladder and prevents displacement of the catheter
3. Material = usually latex, silastic better for long-term placement (less blockage, less infection)
148
French w/ regards to catheter meaning?
Circumference of the catheter in mm
1. Male = 16-18F
2. Female = 12-14F
149
Complications of catheterisation?
1. Early
| 2. Delayed
150
Early complications of catheterisation?
1. Creation of false tract
2. Urethral rupture
3. Paraphimosis
4. Haematuria
151
Late complications of catheterisation?
1. Infection
| 2. Blockage
152
C/I to catheterisation?
Urethral trauma
1. Bloods at urethral meatus
2. High riding prostate
3. Scrotal haematoma
4. Pelvic fracture
153
Other types of catheter?
1. Coude catheter = angled tip may help in big prostates
| 2. Condom catheter
154
Mx of non-draining catheter?
1. Blocked = flush with 20ml sterile NS or consider 3-way
2. Bypassing catheter = consider a condom catheter
3. Slipped into prostatic urethra = flushes but wont drain
4. Catheter has perforated the lower tract on insertion and isnt in the bladder
5. Renal/pre-renal AKI
155
Catheter that flushes but wont drain?
Has slipped into the prostatic urethra
156
TWOC?
1. After 24-72 hours in acute urinary retention
2. May be performed as urology outpatient if retention likely
3. Tamsulosin reduces risk of retention after TWOC
157
Indications for long term catheterisation?
1. Chronic bladder outlet obstruction
2. Neurogenic bladder with chronic retention
3. Complications of incontinence = refractory skin breakdown, palliative care, pt preference
158
Clean intermittent self-catheterisation?
1. Alternative to indwelling catheter in chronic urinary retention
2. Also useful in pts who fail to void after TURP
159
Indications for Clean intermittent self-catheterisation?
1. Chronic retention
| 2. Neuropathic bladder
160
3 causes of a neuropathic bladder?
1. MS
2. DM neuropathy
3. Spinal trauma
161
3-way irrigation Foley catheter indication?
1. Irrigate bladder in pts at risk of clot retention
| 2. E.g. after TURP or in pts with haematuria
162
3-way irrigation Foley catheter features?
3 ports
1. Balloon inflation
2. Drainage (middle)
3. Irrigation
163
Suprapubic catheter indications?
1. Urethral injuries
| 2. Urethral obstruction = BPH, Ca
164
Suprapubic catheter insertion method?
1. US guided insertion of catheter under LA
| 2. Trocar inserted into catheter and unit advanced through skin
165
Complications of suprapubic catheter?
1. Viscus perforation
2. Haemorrhage
3. Malignancy seeding
166
Advantages of suprapubic catheter?
1. Less UTIs
2. Less stricture formation
3. TWOC w/o catheter removal
4. Increased pt comfort
5. Maintain sexual function
167
Disads of suprapubic catheter?
1. More complex = need skills
| 2. Serious complications can occur
168
C/I of suprapubic catheter?
1. Known or suspected bladder carcinoma
2. Undiagnosed haematuria
3. Previous lower abdominal surgery = adhesion of small bowel to bowel wall
169
Acute urinary retention clinical features?
1. Suprapubic tenderness
2. Palpable bladder = dull to percussion, cant get beneath
3. Large prostate on PR = check anal tone and sacral sensation
4. <1L drained on catheterisation
170
Acute urinary retention Ix?
1. Bedside = urine dip, MC&S
2. Bloods = FBC, U&E, PSA (prior to PR)
3. Imaging = US, Pelvic X ray
171
Mx of acute urinary retention?
1. Conservative = analgesia, privacy, walking, running water or hot bath
2. Catheterise = use correct catheter (3-way if clots), STAT gent cover, hourly UO + replace, tamsulosin (reduces risk of recatheterisation after retention)
3. TWOC after 24-72hrs
4. TURP = failed TWOC, impaired renal function, elective
172
JJ stent indications?
1. Relieve ureteric obstruction = stones, tumours
| 2. May be inserted intra-op during renal transplant
173
Method of JJ stent insertion?
1. Retrograde = cytoscopic guidance
| 2. Anterograde = percutaneous
174
Complications of JJ stent?
1. Infection
2. Blockage
3. Displacement/migration
175
Chest drain tube and trocar indications?
1. Drainage of pleural cavities
2. Pneumothorax = traumatic, ventilated, following needle decompression of tension, persistent after aspiration
3. Pleural effusion = malignant, pus, blood, lymph
4. Post-op = thoracotomy, post-oesophagectomy
176
Method of chest drain insertion?
1. Consent and explain procedure to pt
2. Commonly insert smaller drains with seldinger technique
3. Morphine analgesia
4. Clean and drape area
5. ID safety triangle
6. Infiltrate 1% lignocaine to rib below and pleura of ICS
7. Make small 1cm incision just above rib below, blunt dissect with Spencer-Wells down to pleura, sweep finger to clear adhesions and check location
8. Attach drain to bottle and advance it into pleural cavity, directing it postero-inferiorly
9. Close wound and ICD using modified mattress suture
10. Get pt to cough and take deep breaths, check for swinging and bubbling
11. CXR to check location
177
Complications of chest drain?
1. Early
| 2. Late
178
Early complications of chest drain?
1. Pain due to inadequate analgesia
2. Haemorrhage due to NV bundle damage
3. Organ perforation
4. Incorrect location e.g. abdomen
179
Late complications of chest drain?
1. Failure = bronchopleural fistula
2. Long thoracic nerve damage --> winging
3. Wound infection
4. Blockage
180
Removal of chest drain?
1. Remove when no longer swinging or bubbling and CXR confirms resolution of PTX
2. Using 2 people, remove in forced expiration and use mattress suture to close wound
3. CXR to check no new PTX
181
Chest drain bottle indications?
As for chest drain tube
182
Chest drain bottle method??
1. Fill bottle to prime level with sterile level
2. Connect drain to bottle
3. Underwater seal allows one-way flow out of pleural cavity
4. May add suction --> active drainage
183
Chest drain bottle complications?
1. Lifting bottle above the pt can --> retrograde flow into chest
2. Complications of chest tube insertion
184
Fracture plate indications?
Internal fixation of fractures
185
Fracture plate method?
1. Required open reduction
2. Plate aligned with orientation of bone
3. Screws used to fix plate to bone
186
Fracture plate complications?
Relate to fracture, procedure, and the plate
| 1. Plate = infection, failure, malposition of the remodelled fracture
187
Types of fixation?
PEC KDICF
1. Plaster of Paris
2. External fixation
3. Continuous traction = collar and cuff
4. K wires
5. DHS
6. IM nail
7. Cannulated screw
8. Fracture plate
188
Hemi-arthroplasty prosthesis indications?
Intracapsular NOF: Garden 3/4
189
Features of hemi-arthroplasty prosthesis?
1. Fenestrated stem for osseous integration (non-cemented)
2. Shouldered
3. Large head
190
Hemi-arthroplasty method?
1. Placed in theatre under GA
2. Posterior or anterolateral (most common) approaches
3. Head of femur resected and femoral shaft reamed
4. Stem is cemented (Thompson) or uncemented (Austin-Moore)
5. Head relocated and joint function and stability assessed before closure
191
Complications of hemi-arthroplasty prosthesis?
Complications involve the fracture, the procedure, and the prosthesis
1. Early
2. Late
192
Early hemi-arthroplasty prosthesis complications?
1. Cement reaction
2. Deep infection
3. Fracture
4. Dislocation (3%) = squatting and adduction
193
Late hemi-arthroplasty prosthesis complications?
1. Loosening = septic or aseptic
2. Failure = stem fracture
3. Revision = most replacements last 10-15 years
194
Total-arthroplasty prosthesis indications?
OA hip
195
Total arthroplasty features?
1. Femoral component with small head
2. Polyethylene acetabular component
3. Most are cemented
196
Total arthroplasty method?
1. Placed in theatre under GA
2. Posterior or anterolateral (commonest) approaches
3. Head of femur resected
4. Acetabulum and femoral shaft are reamed
5. Stems and cups are trialled to find most suitable
6. Head relocated and joint function and stability assessed before closure
197
Complications of total arthroplasty?
1. Immediate
2. Early
3. Late
198
Immediate total arthroplasty complications?
1. Nerve injury
2. Fracture
3. Cement reaction
199
Early total arthroplasty complications?
1. DVT = up to 50% w/o prophylaxis
2. Deep infection (must remove metalwork before revision)
3. Dislocation = 3%, squatting and adduction
200
Late total arthroplasty complications?
1. Loosening = septic or aseptic
2. Failure = stem fracture, wear
3. Revision = most replacements last 10-15 years
201
IM nail indications?
Form of internal fixation used in the Mx of long bone fractures = femur, tibia, humerus
202
IM nail features?
1. Titanium or titanium alloy
2. Screws insert proximally and distally provide rotational and longitudinal stability
3. Curve fits contour of tibia
203
Dynamisation defn?
Removal of one or more screws from IM nail in order to allow collapse --> increased loading of fracture site --> quicker union
204
IM nail method?
1. Inserted under GA
2. Nail hammered into medulla of bone
3. Screws lock nail in place
205
Complications of IM prosthesis?
1. Fracture during nail insertion
2. Infection
3. Embolus
4. Delayed or non-union
206
Fat embolism syndrome presentation?
SOB, petechial rash, confusion
1. Typically b/w 24-72hrs between injury and onset
2. Resp = dyspnoea +/- chest pain
3. Petechial rash = upper anterior trunk, arms, neck
4. CNS = headache, confusion, agitation
5. Renal = oliguria, haematuria
207
Fat embolism syndrome Ix?
1. ABG = hypoxia, hypercapnia
2. FBC = reduced plts and Hb
3. CT chest
208
Fat embolism syndrome Mx?
1. Supportive = O2, volume resuscitation
| 2. Steroids
209
Stiff neck collar indications?
1. Stabilise the cervical spine in trauma pts
| 2. Used with 2 sandbags and tape
210
Features of stiff neck collar?
1. Comes flat packed and must be assembled
| 2. Hole at front allows access to trachea
211
Stiff neck collar method?
1. Sized by measuring the number of fingers from the clavicle to angle of the mandible
2. "Key dimension" then compared to the sizing peg on the hard collar
212
Complications of stiff neck collar?
Incorrect placement = neck not in neutral alignment, chin not flush with end of chin piece
213
Mannitol indications?
1. Osmotic diuretic
2. Lower ICP
3. Reduces intra-ocular pressure in hyphema
214
Hyphema defn?
Pooling or collection of blood inside the anterior chamber of the eye
215
Mannitol method of administration?
Centrally
216
Mannitol complications?
1. May raise ICP in the long term
| 2. C/I in severe cardiac failure and pulmonary oedema
217
Fogarty catheter indication?
Mx of acutely ischaemic limb secondary to embolus
218
Fogarty embolectomy catheter method?
1. Vascular access gained to femoral artery at groin
2. Catheter passed distal to embolus
3. Balloon is inflated and catheter withdrawn
219
Swan-Ganz catheter indications?
1. Flow directed pulmonary artery catheter
2. Measures PCWP (indirect measure of LA filling pressure)
3. Measures CO
4. Used in cardiogenic or septic shock when accurate haemodynamic data is required
5. Its use has not been shown to improve outcome
220
Swan Ganz catheter method?
1. Used in intensive care setting
| 2. Inserted into a central vein
221
Tru-Cut biopsy needle indications?
Used to take histological specimens from lesions
1. Part of triple assessment of breast lumps
2. Liver
3. Kidney
4. Prostate = transrectally
222
Tru-Cut biopsy needle method?
1. Consent and explain method to pt
2. Anaesthetise area with LA
3. Needle advanced under US guidance
4. Spring handle is pressed, advancing the specimen tray into the target lesion
5. Further pressure fires the surrounding sheath, obtaining a biopsy
223
Complications of Tru-Cut needle biopsy?
1. Bleeding
2. Pain
3. Cancer seeding
224
Renal biopsy indications?
1. Unexplained AKI/CKD
2. Acute nephritic syndrome
3. Unexplained proteinuria/haematuria
4. Systemic disease with renal involvement e.g. SLE
5. Suspected transplant rejection
225
Renal biopsy C/I?
1. Abnormal clotting
2. Single kidney (except Tx)
3. Small kidneys from CKD (increased bleeding risk and too late)
4. Renal neoplasms
226
Renal biopsy procedure
1. Stop aspirin (1wk) and warfarin (2d) in advance
2. Check FBC, clotting and G&S
3. US-guided Tru-Cut needle biopsy
227
Renal biopsy complications?
1. Macroscopic haematuria in 1%
| 2. Transfusion needed in 0.1%
