Procedures Flashcards
Needle gauge for arthrocentesis
25-27 for anesthetic, then 18-22 for aspiration
What to send joint aspirate for?
- cell count with differential
- crystals
- gram stain
- culture
*protein, glucose, LDH no longer recommended
LP Landmarks (Adults)
L2-L3 to L5-S1
PSI Crests are @ L4
LP Landmarks (Infants)
Cord goes to L3
L4-L5 or L5-S1
LP Needle gauge + length
Adult: 3.5” 20G
Child: 2.5” 22G
Infant: 1.5” 22G
LP Tubes
Tube 1: Gramm Stain, C&S +- cell count
Tube 2: Glucose, Protein
Tube 3: Cell count + Diff
Tube 4: HSV/CMV/EBV PCR, Special tests +- cell count +- xanthochromia +- West Nile
LP Normal opening pressures
7-20 cm H20
25 cm in obese patients
28 cm in patients <18
LP Bacterial vs. viral CSF
Bacterial
High Opening Pressure
WBC 500-10, 000
Differential: PMN predominance
Glucose: decreased at 0-40 mg/dL
Protein: elevated at >50 mg/dL
Viral
Normal opening pressure
WBC 6-1000
Lymphocytic predominance
Normal Glucose
Protein normal or mildly elevated
LP Neurosyphilis Testing
**CSF VDRL: **60% sens., very specific
**FTA-ABS CSF: **++ sensitive, ~95% specific
Bartholin’s Drainage
Povidone-iodine
Lidocaine
Elliptical incision
Culture (+ GC/CT PCR)
Word 2-4 mL saline
Leave up to 4 weeks
or pack with gauze
Start sitz in 2 days
Keflex + Flagyl (or Flagyl + STD treatment) if abx desired
Gyne within 2 days to 1 week
Landmarks for Paracentesis
1) Infraumbilical in the midline through linea alba
2) Lateral rectus - 5 cm cephalad and 5 cm medial to ASIS
How much fluid to remove on paracentesis?
As much as possible without manipulation of the patient.
For first time ascites for diagnostic purposes, probably 200-500 mL
For therapeutic relief, at least 5-6 L, but up to 10-12 L safely.
Anything over 5 L is called Large Volume Paracentesis (LVP)
When to give albumin (and how much) for paracentesis?
For LVP > 5 L, 25% Albumin, 6-8 g albumin/L removed (100 mL 25% Albumin has 25 g Albumin). Don’t bother for taps <5 L, no evidence for albumin at any level anyways.
When to send out paracentesis fluid and what to send it for?
Only send if diagnostic tap, symptoms, or cloudy.
Send for:
Cell count, albumin (+ serum albumin for SAAG), culture (in blood culture bottles), +- total protein, glucose, LDH, amylase, gram stain.
Lab Cutoffs for Peritonitis
- >250 PMN’s/mm^3 (TNC x %PMN’s) in non-PD
- >100 PMN’s/mm^3 (TNC x %PMN’s) in peritoneal dialysis patients
SAAG
Serum-Ascites Albumin Gradient
SAAG >1.1 g/dL indicates portal hypertension with >95% accuracy
Post-paracentesis Circulatory Dysfunction (PCD)
Some think it is myth. Can happen hours to days after. Hypovolemia, hyponatremia, renal dysfunction.
Insertion Depth for Right Subclavian CVC
(Height/10) - 2 cm
178 cm = 15 cm
Insertion Depth for Left Subclavian CVC
(Height/10) + 2 cm
178 cm = 20 cm
Insertion Depth Right IJ CVC
Height/10
178 cm = 17 cm
Insertion Depth Left IJ CVC
(Height/10) + 4 cm
178 cm = 22 cm
Landmarks for IJ Insertion
Central: apex of triangle formed by clavicle and sternal and clavicular components of SCM, aim for ipsilateral nipple, 1-3 cm.
Posterior: lateral aspect of clavicular portion of SCM, 1/3 distance from clavicle to mastoid process, aim for sternal notch, 3-5 cm.
Anterior: midpoint of medial aspect of the sternal portion of SCM, lateral to carotid artery, aim for ipsilateral nipple, 3-5 cm.
Landmarks for Subclavian Line Insertion
Infraclavicular: needle at 10 degree angle from surface of chest, entry at medial and middle third of clavicle, 3-5 cm.
Pocket Shot: 1 cm lateral to clavicular head of SCM and 1 cm posterior to clavicle, angle of 10 degrees above horizontal, bevel medially, aim for contralateral nipple, 2-3 cm.
Femoral Vein Landmarks
Place the thumb on the pubic tubercle and the index finger on the anterior superior iliac spine. The femoral vein is typically located at the interdigital space (the “V” of the finger and thumb) just inferior to the inguinal ligament.
IO Needle Sizes
- Pink needle: < 40 kg, 15 mm
- Blue needle: > 40 kg, 25 mm
- Yellow needle: > 40 kg, 45 mm (for prox humerus in adults)
Optimal size leaves one 5 mm mark above the skin on needle after soft tissue penetration
IO Flow Rates
- Proximal Humerus: ~5 L/h
- Prox Tibia: ~1 L/h
- Both with 300 mm Hg pressure bag*
IO Site Care
- Remove after 24 h
- Discourage ambulation with tibial IO
- Do not lift/abduct arm with deltoid IO (may dislodge)
- Check hourly for extravasation
- No restrictions after removal
IO Lidocaine Flush Dosing
Lidocaine flush: 0.5 mg/kg (1% or 2% lidocaine) then 10 mL NS flush, then 0.25 mg/kg lidocaine if needed, then infusion of meds and 0.25 mg/kg Q45 min PRN
IO Insertion Landmarks
Review on Evernote “IO”
IO Contraindications & Risks
Contraindications
- # , infection, no landmarks, prev significant ortho procedure at same site
- IO use in same bone within 48h
Risks
- ~1% (extravasation, compartment syndrome, local infection)
- 1/100,000 osteomyelits
Intercostal Nerve Block
Review on Evernote
Wrist Blocks
Review on Evernote
Femoral Nerve Block
Review on Evernote
Posterior Tibial Nerve Block
Review on Evernote “Ankle Blocks”
Thoracentesis
Evernote
Pneumothorax management
-
primary pneumo (no lung disease, no trauma)
- < 3 cm apex-cupula (or less than 20% lung volume) + stable (full sentences, >90%, normotensive, HR 60-120)
- may treat with O2 for 4h, repeat CXR, if better or no progression, RTED in 24h for R/A
- > 3 cm apex-cupula
- 16-22 Fr Chest tube or pigtail catheter to Heimlich + home (R/A 48 h) or water seal -20 mm Hg suction + admit
- < 3 cm apex-cupula (or less than 20% lung volume) + stable (full sentences, >90%, normotensive, HR 60-120)
-
secondary pneumo (pre-existing lung disease or trauma)
- admit
- probably all need chest tubes
- Keflex/Ancef x 24-48 h
