Procedures Flashcards
Lumbar Puncture
2021.2 Teaching station
2023.2 Teaching station
Indications:
- diagnostic procedure
(subarachnoid haemorrhage, meningitis, encephalitis, opening pressures in IIH)
CONTRAINDICATIONS:
- non compliant patient
- INR >1.5
- Platelets <100
- recent anticoagulation
- overlying cellulitis
- trauma to lumbar spine
- haemodynamically unstable
COMPLICATIONS:
- post LP headache
- failed procedure
- back pain, radicular pain
- epidural haematoma
- infection
- epidermoid tumours
- brain herniation
WHEN TO GET CT:
- signs of raised ICP (papilloedema)
- reduced LOC
- new seizures
- focal neurological deficit
CT findings:
- midline shift
- obliteration or overcrowding of the basal cisterns
- hydrocephalus
PATIENT POSITION
- upright preferred (easier to identify midline and spinous process)
- sit edge of bed
- chair supporting feet
- hips flexed >90 degrees
- hug pillow to increase flexion at the lumbar spine
- lateral decubitus position if required to measure opening pressure
LANDMARKS:
- iliac crests are at the level of L4/L5 spinous processes
- palpate midline and interspinous space
- mark space with needle cap
can use USS to find interspinous space and identify ligamentum flavum
PPE:
mask
grown
sterile gown
sterile gloves
- Prep skin with chlorhexidine
- Infiltrate subcutaneous tissue with lignocaine 1% 5ml (max 3mg/kg), infiltrate down to interspinous ligament
- insert cutting introducer needle, angle cephalad toward the umbilicus
POST LUMBAR PUNCTURE HEADACHE:
- 24-48hrs post LP
- worse with sitting, standing cough and valsalva
- better lying supine
Risk factors:
- use of large bore needles
- using a cutting needle
- multiple dural punctures
- failure to replace the stylet when withdrawing the needle
Use smallest bore needle required for procedure. 22G if need to measure opening pressures otherwise use 25G.
Use pencil point needle not cutting needle
avoid multiple dural punctures and replace the stylet
SEDATION:
Midazolam 1-2mg IV (anxiolysis)
Morphine 2.5-5mg IV (analgesia)
Ketamine 10-20mg IV (sedation, analgesia, dissociation)
Femoral Nerve Block
Fascial Illiaca Block
Lateral Canthotomy
Paediatric IO Placement
2021.1 Teaching Station
Paediatric IO Placement
INDICATIONS:
- urgent IV access required
CONTRAINDICATIONS:
- fracture at the insertion site
- Proximal injury
- Bone pathology (osteogenesis imperfecta)
- Overlying skin cellulitis or burn
- Previous IO insertion at same site
CONSENT:
- give brief explanation of procedure if patient is alert
COMPLICATIONS:
- Pain
- Failed procedure (misplacement)
- Fracture or epiphyseal injury
- Fat embolism
- Compartment syndrome
- Infection (osteomyelitis)
INFECTION CONTROL:
- Wash hands
- Non-sterile gloves
Proximal tibia for paediatric patients
- Identify patella
- Palpate tibial tuberosity
- 1-2cm distal and medial
POST PROCEDURE:
- check for complications
- remove IO once IV access obtained
- document procedures, attempts, complications if any
DISCUSSION:
- Marrow can be used for POC glucose and cross match
- All IV drugs and blood products can be given through I
- Gravity is insufficient to drive fluid through IO, need pressure bag or pump set
- Recommend humerus placement in adults. Humerus IO have faster infusion rates 150ml/min and less painful, but higher rates of dislodgement.
- Recommend proximal tibia placement for paediatrics (greater risk of fracture and epiphyseal injury in the immature humerus)
- Can use lignocaine 2% up to 3mg/kg
Needle size:
PINK 15mm - neonates and small children at proximal tibia
BLUE 25mm - children > 40kg in humerus, adults in proximal tibia
YELLOW 45mm - adults at humerus
Airway Skills - Cricothyroidotomy
2022.1 Teaching Station
- Predictors of the difficult airway
- Preparation for difficult intubations
- Cricothyroidotomy procedure
PREDICTORS OF DIFFICULT AIRWAY:
DIFFICULT AIRWAY ASSESSMENT:
GENERAL:
Obesity, OSA, pregnancy
Trauma - orofacial, neck, airway burns
MOUTH:
Receding mandible
Limited jaw opening
Large protruding teeth
PHARYNX/LARYNX:
Tumours - larynx/pharynx
Infection - ludwig’s angina, epiglottitis
Anaphylaxis/angioedema
NECK:
Short muscular neck
Limited neck extension – OA, ankylosing spondylitis, spinal fusion
Spinal immobilisation
Predictive systems:
3:3:2
Mouth opening – 3 finger breadths
Thyromental distance – 3 finger breadths
Thyrohyoid distance – 2 finger breadths
Mallampati III & IV considered difficult airways
III – can only just see the soft palate, uvula is obscured by base of tongue
IV – soft palate not visible
PREPARATION FOR DIFFICULT AIRWAY:
Pre-oxygenation: Sit up right, 15L NRB + nasal cannulae
Mark FON landmarks
Plan A: Video laryngoscopy with bougie
Plan B: rescue with a supraglottic device (e.g. i-gel, LMA).
Plan C – cricothyrotomy.
Pelvic Binder
2022.1 Teaching Station
teach them about the use of pelvic binder systems
* describe the fitting of a pelvic binder system
* explain post pelvic binder application management
INDICATIONS:
trauma +
- suspected pelvic fracture (especially open book fractures and vertical shear fractures)
- hypotension (even transient hypotension)
- cardiac arrest
- pelvic instability on primary survey
MECHANISM OF ACTION:
- reduces venous and cancellous bone bleeding by reducing pelvic volume thereby promoting tamponade and clot formation
CONTRAINDICATIONS:
- Lateral compression fracture - may cause harm from further lateral compression
COMPLICATIONS:
- misplacement (common)
- painful
- pressure sores with prolonged use
PROCEDURE:
3-4 ppl
T-pod or Sam Sling
OR sheet with 4 clamps
premedication with analgesia - ketamine 10-20mg IV slow push
Palpate greater trochanters - lateral to the top of pubic symphysis
POST PROCEDURE:
- check tension and position at greater trochanters
- document time of application
do not log roll, can perform 20 degree tilt to palpate spine
put down pelvic binder ahead of time
Biers block
Transcutaneous Pacing
INDICATIONS:
- symptomatic bradycardia refractory to medications
- overdrive pacing in tachyarrythmias refractory to medications and DC cardioversion
Temporising measure until patient receives transvenous pacing or definitive management
COMPLICATIONS:
- failure to pace
- painful
SEDATION:
- low dose ketamine 10-20mg IV boluses then infusion 0.3mg/kg/hr
- sedation, dissociation, amnesic, analgesic
- maintain own airway
- haemodynamically stable
CORRECT PAD PLACEMENT
- AP position
- anterior pad covers the left parasternal window of the heart
- posterior pad just below the scapula
Pacer mode
Set rate - 60bpm
Set current - start low and titrate up. start at 30mA
Electrical capture
Mechanical capture
continue pacing 10-20mA above minimum energy required for capture
usually 40-80mA but may need higher current in obesity and COPD
Be aware of pseudopacing
check for mechanical capture:
- palpate femoral artery
- pulse oximetry
- POCUS
VBG interpretation
DKA
Vomiting in hyperemesis gravidarum
Shocked patient
Reduced LOC
Seizure at a nightclub
3 days of vomiting
presumed gastroenteritis and hypotension
Toxicology - agitated patient, HAGMA
1yr infant in cardiac arrest
Anion gap = Na+ - Cl- -HCO3-
expected CO2 = 1.5 x HCO3- +8
complete respiratory compensation
expected CO2 in metabolic alkalosis
= (0.7 x HCO3) + 20
Corrected Na+ in hyperglycaemia
Corrected Na+ = Na+ + (Glucose – 5 ÷ 3)
Delta ratio = (change in anion gap) / (change in bicarbonate)
* This can reveal any mixed acid-base disorders
- Less than 0.4 = pure normal anion gap acidosis
- 0.4-0.8 = mixed high and normal anion gap acidosis
- 0.8-2.0 = pure high anion gap acidosis
- More than 2.0= high anion gap acidosis and a pre-existing metabolic alkalosis
Incision & Drainage of Abscess
2023.1 teaching station
EM cases podcast episode 109
Indication:
- reasonably superficial abscess, not draining spontaneously
Contraindications:
- anorectal abscess
- abscesses near major nerves or blood vessels (eg, facial nerve, carotid artery, femoral artery).
- Central triangle of the face (intra-cranial infections)
- breast abscess involving nipple or areolar
Patient counselling:
- about the procedure
- risk of scarring and keloid formation
ANALGESIA:
I&D is very painful
local anaesthetic injected into the abscess is less effective due to the lower pH of infected tissue, which reduces the proportion of anesthetic in the more active uncharged form.
Performing a “field block” or “ring block” in the health tissue surrounding the abscess is more effective
use large volumes lignocaine 1% with adrenaline (max dose 5mg/kg)
Give oral or IV analgesia
PROCEDURE:
number 11 scalpel blade
Linear incision
USS guided needle aspiration
Loop drainage for larger abscess have better cosmetic outcomes
stab incision to limit tissue injury and scarring
Culture for mcs -
- multiple medication allergies where your antibiotic choices are limited
- treatment failure
Probe wound with gauze, breakdown locations
Irrigation with saline for larger abscess
- reduce bacterial load
Closing:
abscesses should be left open to heal by secondary intention (secondary closure).
Loose packing with iodine soaked ribbon gauze for larger abscess >5cm. leave 1cm out of wound so that it can be easily removed at next review.
Cover with dressing
Consideration of antibiotic treatment:
- not necessary if systemically well and abscess has been drained effectively
- consider in immune compromised
- shared decision making with the patient
- minimal benefit if effective I&D
- side effects (GI upset), eradication of natural flora leading to opportunistic infections like thrush and Clostridium difficile, hypersensitivity reactions
- NNT 10, NNH 10
- ?cover for MRSA
MRSA risk:
- previous MRSA
- live in area with high prevalence (NT, northern queensland)
- hospital admissions
- aged care facility
- corrections
ADT prophylaxis
Discharge planning and follow up:
GP follow up in 2 days for wound review and removal of packing
simple analgesia
return advice - unwell with fevers, increasing redness and pain
Epistaxis
2023.1 Teaching station
Teach a junior registrar (role player) a stepwise approach
to an adult patient with an ENT emergency, whilst describing the use of specific ENT equipment.
Anterior bleeds:
- ruptured vessel in little’s area
- 90% of bleeds
Posterior bleeds:
- branch of sphenopalatine artery
- typically older patients on anticoagulation
- 10% of bleeds
MANAGEMENT:
1) Visualise the bleed
Blow nose and flush out existing blood clots
Nasal speculum - different sizes
Suction can help
Cophenylcaine spray
Sit up, Compression of littles area 30min
Ice cubes in mouth can reduce nasal mucosa blood flow by 25%
ANALGESIA:
- painful intervention
- cophenylcaine (lignocaine + phenylephrine)
SILVER NITRATE CAUTERY:
- only effective for small focal light bleeds
- wear PPE because it will make people sneeze
- apply to small area, for 5-10sec
Septal necrosis and perforation if cauterise septum from both nares.
Surgicel or Kaltosat
ANTERIOR PACKING:
Tranexamic acid soaked tampon or balloon device
Merocel tampon
Rapid Rhino anterior packs come in 4.5-7.5cm lengths
Bilateral if unilateral packing unsuccessful in controlling haemorrhage
can discharge home and return in 24-48hrs for removal
no need for antibiotics to prevent sinusitis or toxic shock syndrome
POSTERIOR PACKING:
Rapid Rhino
- posterior pack has 2 balloons and 9cm length
- posterior balloon 30ml
- anterior balloon 10ml
- must be removed by 24 hours due to risk of mucosal damage/necrosis
Inflate posterior balloon with air 20ml
pull forward until caught on middle turbinate
inflate anterior balloon
Foley catheter
- use a 20 - 30 mL balloon 10-14 F gauge catheter
- cut the tip off the catheter just distal to the balloon
- insert catheter into the nostril and pass it into the nasopharynx
- visualise the catheter tip is in the correct position through the patient’s open mouth
- fill the balloon with 7 mL of H2O
- seat the balloon in the nasopharynx then place an additional 7 mL in the balloon
Posterior bleeds with posterior packing need admission for monitoring
OPERATING THEATRE:
- posterior cautery under GA
- sphenopalatine artery (branch of internal maxillary artery)
- internal maxillary artery (branch of the external carotid artery)
- anterior ethmoidal artery
Interventional Radiology
- Embolisation
- internal maxillary artery
- stroke risk 1:100
- complications: facial pain, headaches
CONSIDERATION OF ANTICOAGULATION REVERSAL:
- the indication for warfarin therapy - metalic cardiac valve, stroke risk if not anticoagulated
- the current INR value - would be inclined to reverse if INR was dramatically elevated >10 for example (avoid using vitamin K as this will prolong time to re-coagulation)
- haemodynamic instability
- ongoing bleeding with need for blood transfusion
Priapism
Compartment syndrome of the penis - is a urological emergency
can lead to permanent impotence if left untreated (4-6hrs). will never get an erection again. will need penile implant.
Medications that cause ischemic priapism:
- Intra-cavernosal injections:
“triple mix” - papaverine,
- prostaglandin E1
- phentolamine
- PDE5 inhibitors (sildenafil, tadalafil)
*Anti-hypertensives
- hydralazine
- prazosin
- calcium channel blockers
- Neuroleptics: chlorpromazine
- Drugs of abuse: cocaine, marijuana
Low flow (ischemic) priapism:
- associated with medications & sickle cell disease
- venous obstruction
- severe pain
- acidotic penile blood gas
- 98% of priapism
- corpus cavernosum will be hard, glans will be soft
VBG - pH < 7.2, CO2 >60, high lactate, low glucose
High flow (non-ischemic) priapism:
- associated with trauma (straddle injury) and spinal cord injury
- not painful
- 2%
MANAGEMENT:
ANAESTHETISE:
dorsal nerve block:
- 2 & 10 o’clock deep to bucks fascia
- 1% lidocaine without adrenaline 2ml (max dose 4ml/kg)
ASPIRATION:
large bore 18G butterfly needle
insert into either corpus cavernosum at 2 or 10 o’clock
avoid the urethra inferiorly
avoid neurovascular bundle superiorly (dorsal nerves, arteries, veins)
corpus cavernosum communicate so usually only have to drain one side
aspirate 20ml blood and send for VBG
IRRIGATION:
if not able to aspirate –> irrigate with 20ml sterile saline (to break down clot)
INJECTION OF SYMPATHOMIMETICS:
phenylephrine 200mcg, repeat every 5min (max 1mg)
adrenaline
Others:
- pseudoephidrine
- squatting
Urinary Retention
CAUSES of urinary retention
Obstructive:
- BPH
- Prostate cancer
- Haematuria with clot retention
- urethral strictures
- vaginal prolapse
- faecal impaction
Infection:
- cystitis
- genital herpes simplex in females (painful)
Neurological:
- cauda equina
- transverse myelitis
Medications:
- anticholinergics
POST OBSTRUCTIVE DIURESIS:
- electrolyte abnormalities and massive fluid losses that need replacing
DISCHARGING HOME WITH IDC:
- leave in for approximately 7days to regain detrusor muscle co-ordination and strength after being overstretched for a prolonged period
- follow up in urology clinic
Approach to difficult urinary catheter insertion: Key steps
ANALGESIA:
pelvic muscles need to be relaxed
- fentanyl 25-50mcg IV
- use lots of lubricant with lidocaine
- slow intra-urethral injection (rapid injection is painful and can cause tightening of pelvic muscle which will make IDC placement difficult)
CATHETER SIZE:
- 16F is the usual adult size
- if BPH use larger size –> 18F
- use smaller sizes in urethral strictures
TECHNIQUE:
- penis should be held perpendicular to the patient, meatus facing the ceiling
- inject lubricant with lidocaine slowly then hold the meatus
SUPRAPUBIC CATHETERS:
Indications:
- failed IDC usually due to urethral stricture or complex prostate pathology/surgery
- urethral disruption due to trauma
- no urological services to place urethral catheter
Contraindications:
- bowel anterior to bladder
- overlying cellulitis
- coagulopathy
Procedure:
Seldinger set up
Anesthetise 3-5ml with adrenaline
POCUS to identify the bladder - ensure no bowel between wall and bladder
Midline, 2 finger breadths above pubic symphasis
Insert needle and aspirate urine
Insert guidewire
Remove needle
Dilate tract
Remove dilator
Railroad IDC over guidewire
Aspirate urine
Inflate balloon
Biers block
prilocaine 0.75% 2-3mg/kg
duration of action 30-60min
CONTRAINDICATIONS
- confused unco-operative patient
- uncontrolled hypertension SBP >180mmHg
- allergy to local anaesthetics
- humerus fractures
- Crush injury or compartment syndrome
- G6PD deficiency
- Sickle cell disease
COMPLICATIONS:
- pain at the tourniquet site
- tourniquet failure leading to local anaesthetic toxicity
- anaphylaxis
PLACE:
- resuscitation area
- cardiac monitoring and pulse oximetry
STAFF:
EQUIPMENT:
Prilocaine or lignocaine
Prilocaine 0.5% mixed with equal parts 0.9% NS (max dose 3mg/kg)
2x IV cannulas
Pneumatic tourniquet
Cotton padding wrap
Plaster equipment
PROCEDURE:
Continuous cardiac monitoring
Pulse oximetry
BP cycling every 3min
record baseline BP
place 2 IV cannula
- one in the non-operative hand
- one in the operative hand (as distal as possible)
place cotton padding around upper arm
place pneumatic tourniquet upper arm
raise the arm for 1min to allow for passive exsanguination
Inflate tourniquet 250 mmHg, or 100 mmHg SBP.
start the timer.
Check for brachial and radial pulse
slowly inject prilocaine over 1min
remove IVC and apply firm pressure and dressing
Assess for anaesthesia
Perform procedure
The tourniquet should be left inflated after injection of local anesthesia for at least 20 minutes,
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Stop procedure
Call for help
Ensure tourniquet/cuff inflated (inflate cuff to 100mm Hg above systolic BP)
- Support airway - jaw thrust / chin lift - Supplemental oxygen 100% high flow 15L NRBM
- Terminate prolonged seizure with IV Midazolam 2.5-5mg
- Seek and treat ventricular dysrhythmias with sodium bicarbonate 2mmol/kg IV, repeat every min
- Seek and treat cardiovascular collapse with intralipid 20% 1ml/kg IV bolus
(Intralipid contraindicated in soy, egg, penut allergic patients)
