Procedures Flashcards
Lumbar punture contraindications
Raised ICP
Back infection or contamination
Back malformation or surgery
Anticoagulation / antiplatelet
Landmarkings for lumbar puncture
Supracristal plane - Spinous process of L4 should be marked.
Intervertebral space of L4
Insert 90 degrees, slightly cranial
Lumbar puncture measurements
Measure pressure
3x tubes:
Micro for cell count, serology and culture
Biochem for protein and glucose, cytology
Immunology for antibodies
DPL - contraindication
Existing need for laparotomy
Previous abdominal operations, morbid obesity, advanced cirrhosis, coagulopathy
DPL - indication
To facilitate diagnosis of intra-abdominal perforation or bleeding
DPL results indicating need for surgery
> 10ml frank blood or obvious enteric contents on aspirate
100000 RBC
500 WCC
+ gram stain for bacteria
Complications of DPL
Haemorrhage secondary to skin incision - false positive
Intestinal perforation
Laceration of bladder
Injury to other abdominal structure
Wound infection
Paracentesis location
USS + percuss out
Aim 2cm below umbilicus, 5cm superior and medial to ASIS
Complications of paracentesis
Failure
Leak
Infection
Haemoperitoneum
Perforation of hollow viscous
Pericardiocentesis location
1-2cm inferior and to the left of xiphochondral junction
Advance towards tip of left scapula
Complications of pericardiocentesis
Aspiration of ventricular blood
Lac ventricular myocardium
Laceration of coronary artery or vein
New haemopericardium
VF
Pneumothorax
Puncture of great vessels and worsening tamponade
Puncture of oesophagus and mediastinitis
LA doses
Ropivocaine 0.75% - 2mg/kg
Marcaine 0.5% - 3mg/kg
Lignocaine 1% - 4mg/kg
Landmark for intercostal nerve block
Angle of the rib, 6-8cm from the spinous process, inject below rib, aiming for NV bundle.
Inferior scapula = 7th rib
SPC insertion contraindications
Previous lower abdominal / pelvic surgery
Anticoagulation
Bleeding risk
Process of SPC insertion
LA 2 fingers above PS
Insert spinal needle with syringe, caudally
Aspirate until urine flows, advance 1cm further
Remove syringe, place guidewire
Remove needle
Skin nick
Dilator
Guidewire out, trochar out
Catheter in, aspirate urine
Inflate balloon with 10ml sterile water
Peel away tube
Attach urine bag, monitor UO
Document, dispose of sharps in sharp bin
Change at 3 weeks
Process of SPC insertion
LA 2 fingers above PS
Insert spinal needle with syringe, caudally
Aspirate until urine flows, advance 1cm further
Remove syringe, place guidewire
Remove needle
Skin nick
Dilator
Guidewire out, trochar out
Catheter in, aspirate urine
Inflate balloon with 10ml sterile water
Peel away tube
Attach urine bag, monitor UO
Document, dispose of sharps in sharp bin
Change at 3 weeks
Process of SPC insertion
LA 2 fingers above PS
Insert spinal needle with syringe, caudally
Aspirate until urine flows, advance 1cm further
Remove syringe, place guidewire
Remove needle
Skin nick
Dilator
Guidewire out, trochar out
Catheter in, aspirate urine
Inflate balloon with 10ml sterile water
Peel away tube
Attach urine bag, monitor UO
Document, dispose of sharps in sharp bin
Change at 3 weeks
Femoral nerve block landmark
Lateral to femoral artery
Midpoint ASIS and pubic tubercle, then 2cm lateral and 2-3cm below this
2 clicks - skin and sheath
Intravascular injection of local
CNS - circumoral paraesthesia, tinnitus, tremor, decreased LOC, seizure
CVS - decreased BP, arrhythmia
Saphenous vein cutdown landmarking
2cm anterior and superior to medial malleolus
Complications of saphenous vein cutdown
Haematoma
Phlebitis
Cellullitis
Saphenous nerve division - loss of sensation to medial aspect of foot
Thrombosis
Embolism
NG insertion length
Measure from tip of nose, to ear lobe, then to just below the xiphisternum
How to confirm positioning of NG
Tube aspirate gastric contents
Tube aspirated pH below 5
CXR
Capnography
Contraindications to NG insertion
Base of skull fracture
Mid face trauma
Choanal atresia
Recent nasal / adenoid surgery
Oesophageal atresia
Oesophagectomy
Caustic ingestion
Breast FNA - Risks
Infection
Haematoma
Repeat FNA / biopsy
False negative
Breast FNA - procedure
Consent, hand hygiene, introduce etc
Prep skin
Fix lump between thumb and finger of one hand
Use 25G needle and insert into lesion, pass back and forward at multiple trajectories, no need for syringe
Attach syringe with 10ml air
Gentle express needle contents onto slide
Use other slides to smear sample
If not enough - use 21G needle again
Digital extensor tendon splint
Apply for extensor tendon injury
Long aluminium splint with foam
Apply to dorsal aspect of digit over hand and wrist
Tape before and after it crosses each joint
Mallet splint application and management
Patient lying flat on table
Slip mallet splint over
Tape proximal end around finger
Can bath and shower with it on
Afterwards - rest hand flat on table next to sink
Slip splint off and sponge wash hand while keeping it still
Replace and tape
Needs to be on for 6 weeks
Will review in clinic with hand therapist and repeat XR
Cervical collar application
Measure from trap to angle of jaw
Place back on first and then front
Secure
Arthrocentesis general procedure
Skin prep
22G needle and syringe with LA
18G needle and 30ml syringe with aspirate
Wash hands + gloves
Knee arthrocentesis procedure
Position supine, knee flexed slightly with towel underneath
Needle placed at superolateral aspect of patella heading into joint space
Shoulder arthrocentesis procedure
Position: sitting
Needle placed inferolateral (~1cm) to coracoid process heading into joint space
Direct needle posteriorly toward glenoid rim
Wrist arthrocentesis procedure
Position sitting, wrist resting on towel roll on the table face down
Needle placed distal to Lister’s tubercle (radius), ulna to EPL
1st MTP arthrocentesis
Foot on bed, knee flexed
Needle placed medial to EHL on dorsal aspect, towards joint space which is opened up by applying axial traction (pull on the big toe)
Femoral nerve block losses
Loss of anterior-medial thigh and medial leg and medial malleolus sensation
Loss of quadriceps, pectineus and psoas muscles
Loss of hip joint sensation
