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Oral Boards > Procedures > Flashcards

Procedures Flashcards

1
Q

GENERAL INTRO

A 
obtained informed consent
follow sterile precautions 
appropriate PPE
equipment 
position
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2
Q

simple intubation

A 
adjuncts - oral/nasal airway, bougie, LMA, cric, sizes
backups - RT, vent
BVM
NC for passive oxygenation
sniffing position
Mallampati score
landmarks for cric
preoxygenation
premedication - lidocaine for TBI, atropine for peds
Sedation - etomidate - 0.3 mg/kg
Paralysis - rocuronium - 1 mg/kg
Placement - direct visualization
Confirm - humidity, chest rise, ausculate both lungs and epigastrically, ETCO2
Secure Tube
X ray to confirm
Hook to Vent - RR 15, FIO2 50%, PEEP 5, TV 4-6cc/kg
Sedation 
ABG in 15 minutes
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3
Q

cricothyroidotomy

A

immobilizing the larynx
ketamine and lidocaine if time persists
identify cricothyroid membrane
2 cm vertical incision through the skin and subq
2 cm horizontal incision through the membrane
tracheal hook to grasp inferior border of thyroid cartilage
dilate the cricothyroid membrane
place tracheostomy tube - shiley 5, ETT 6
secure
connect to BMV

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4
Q

awake fiberoptic intubation

A

glycopyrrolate (0.1 mg /kg) for secretions
nebulized/topical lidocaine for anesthesia
slide ETT over fiberscope
advance scope to posterior pharynx, visualize cords, pass tube

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5
Q

simple intubation

A

adjuncts - oral/nasal airway, bougie, LMA, cric, sizes
backups - RT, vent
BVM
NC for passive oxygenation
sniffing position - EAM parallel to sternal notch
Mallampati score
landmarks for cric
preoxygenation
premedication - lidocaine for TBI (1.5 mg/kg), atropine for peds (.01 mg/kg, max of 1 mg)
Sedation - etomidate - 0.3 mg/kg
Paralysis - rocuronium - 1 mg/kg
open mouth wide, insert laryngoscopy blade until epiglottis is in view, insert blade into vallecula, lift upwards and outwards to visualize the vocal cords
Placement - direct visualization
Confirm - humidity, chest rise, ausculate both lungs and epigastrically, ETCO2
Secure Tube
X ray to confirm
Hook to Vent - RR 15, FIO2 50%, PEEP 5, TV 4-6cc/kg
Sedation
ABG in 15 minutes

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6
Q

percutaneous transtracheal ventilation

A

children under 10
locate cricothyroid membrane
immobilize larynx, advance 14g syringe to 20cc syringe
needle placed at a 45% angle, advance inferiorly
advance into trachea until air is aspirated in syringe
connect with adapter to BVM and ventilate
pressure start 20 lb/in sq
increase pressure to maintain sats

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7
Q

arthocentesis

A

mark the site, sterilize with iodine, sterile field
US guidance if possible
18g needle attached to 20 cc syringe
advancing slowing while negative suction with syringe plunger
see, hear, or feel a “pop” once inside the joint
aspirate contents and withdraw the needle
repeat neurovascular exam

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8
Q

tube thoracostomy

A

supine position, arm above head
sterile precautions, prep with iodine, drape
anesthesize superficially + deep near pleura
4th intercostal space, mid axillary line
incision superior and parallel to the rib
dissect down with kelly clamp, puncture pleura
rush of air, withdraw kelly while spreading tract
insert gloved finger into space to confirm
place chest tube directed posterior and superior
advance until all drainage holes are in pleura
secure with sutures / occlusive dressing
connect to Pleurovac to suction (-20 cm of H20)
confirm with XR

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9
Q

needle thoracostomy

A

locate landmark: 2nd intercostal space, midclavicular line
sterilize with iodine
14 g needle, 6 cm
superior edge of 3rd rib, perpendicular to chest
advance until feel pop or hear rush of air
remove needle, leave catheter
procede to place definitive tube thoracostomy

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10
Q

CVL

A

identify site, R IJ, iodine to sterilize
gown, gloves, mask, surgical hat
position supine, head 10 deg down
anesthetize with lidocaine
ensure all ports flush appropriately
under US guidance advance needle and syringe toward vein slowly with negative pressure from plunger
flash of blood, remove syringe from needle, thread guidewire gently into vessel, confirm location with US
remove needle, use scapel to create superficial opening, dilate tract, place triple lumen catheter over guidewire, remove guidewire
flush/aspirate, secure, occlusive dressing
confirm with XR

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11
Q

newborn care / resus

A 
warm and dry infant
stimulate
clear airway
APGAR: color, tone
assess for meconium?
cyanosis --> give o2
HR < 100 --> PPV
HR < 60 --> compressions
4th line - epi, IVF
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12
Q

escharotomy

A 
no need to anesthesia
sterile precautions
longitudinal incision, avoid joints
lateral and medial, mid-axial
incise down to the subcutaneous fat
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13
Q

fracture / dislocation

A 
patient laying supine (traction / countertraction)
assist provides countertraction
gently traction in line with deformity
until successfully reduced
place in splint / brace
repeat neuro/vascular exam
obtain post reduction x ray
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14
Q

IO

A

proximal tibial, anterior and medial flat surface, 2 cm below the tuberosity
sterilize with iodine, anesthetize with lidocaine
needle placed perpendicular, pressure applied
connected to drill, advanced through cortex
stylet removed, aspirate marrow
flush with lidocaine and saline
secure to skin, connect to IV tubing

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15
Q

lateral canthotomy = retrobulbar hemorrhage

A

supine
irrigate eye
sterilize with iodine, anesthesize with lidocaine
crimp lateral canthus with hemostat
scissors to cut laterally to the orbital rim, avoiding the globe
expose the inferior crus of the lateral cathus tendon and incise to relieve pressure
- no improvement - incise superior crus
- optho management

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16
Q

lumbar puncture

A

assure no contraindications - bleeding risk, ICP
lay patient in lateral decub, “curl like a cat”
sterile technique, anesthetesize
L4-L5 spinous process
18g spinal needle bevel facing upwards, direct to umbilicus
advance slowly, withdraw stylet frequently to check for CSF return
measure opening pressure
collect 4 tubes
replace stylet, withdraw needle, cover with bandage

17
Q

PTA aspiration

A

patient seated
anesthetize with lidocaine
laryngoscope to retract the tongue and provide light
3 inch 18g needle attached to 10cc syringe
trim sheath of needle, so only 1.5 cm exposed
advance foreward into the center of the cavity
aspirate contents, retract needle slowly

18
Q

paracentesis

A

LLQ, lateral to rectus abdominis
sterilize with iodine, anestetize with lidocaine
insert needle in horizontal place
retract skin to prevent leak
slowly advancing and aspirating until fluid reached
aspirate contents
remove needle

19
Q

pericardiocentesis

A

position with 30 deg head elevation
sterile technique, anesthetise epigastric area
US guidance or 12 lead
insert 18g, 5 in spinal needle subxiphoid approach
directed to the left scapula while aspirating syringe
continue to advance until fluid aspirated
confirm location with US, ST elevation on EKG
aspirate as much fluid as possible
place drain using seldinger technique
post procedure x ray, vitals
call cardiothoracic surgery for a window

20
Q

perimortem C-section

fundus 3 cm above umbilicus

A

continue CPR and maternal resuscitation
displace the uterus to the left
midline incision from symphysis pubis to the umbilicus (past if needed)
cut through all layers of abdominal wall to expose the uterus
5cm vertical incision to the lower uterine segment avoiding fetal injury
use fingers to lift uterine wall away from fetus
scissors to extend the incision to the fundus
deliver infant
- continue maternal resuscitation

21
Q

suprapubic catheterization

A

suprapubic area are surgically prepped and draped
22g spinal needle placed midline 2 cm above symphysis pubis
directed 15 deg inferiorly
advanced until urine aspirated
guidewire is placed
scapel used to break superficial skin
trochar is placed into the badder using seldinger technique
inner sheath is removed
suprapubic catheter placed through outer sheath
confirm placement with drainage of urine
outer sheath is removed
catheter is secured

22
Q

thoracotomy

A

intubated, right mainstem to collapse left lung
sterilize skin
#20 blade and dissect along 5th intercostal space from sternum to posterior axillary line
puncture and cut intercostal muscles with mayo scissors
identify pleura, cut through to enter thoracic cavity
insert rib spreader with ratchet down and open chest
lift lung, identify pericardium
perform pericardiotomy (anterior to phrenic nerve and perpendicular to skin incision)
evacuate blood from pericardium
tamponade myocardial bleeding with foley catheter
purse-string suture around wound
open heart massage
locate aorta and cross-clamp
pulmonary hemorrhage, cross-clamp hilum

23
Q

testicular detorsion

A 
supine position
rotate medial to lateral
attempt rotation in opposite direction
further rotation for partial improvement
successful detorsion signaled by relief of pain and normal position of testicle
referral for operative exploration
24
Q

transcutaneous pacing

A 
place pads on the patient
analgesia / sedation as needed
verify mode is set to pacing
set rate at 70
set current at lowest, increase until capture obtained
confirm with 12 lead EKG
prepare for transvenous pacing
25
Q

transvenous pacing

A

same as CVL

float pacer into right ventricle

26
Q

delivery

A

patient in dorsal lithotomy position
prep perineum with iodine, sterile drape
digital traction to inferior perineum
episiotomy if needed - 3 cm incision at posterior fourchette
pressure on fetal head to keep in extension
when head delivered - suction nose and mouth
feel neck for cord - clamp and cut if necessary
gentle downward traction to deliver anterior shoulder
guide fetus upward to delivery posterior shoulder and rest of body
cut and clamp umbilical cord
warm and stimulate infant
continue to monitor mother and child

oxytocin 10 ml/min
methergine 0.2 mg IM

27
Q

FAST exam

A

probe in subxiphoid place directed towards the left to look at pericardium
probe between R 10-11 ribs - hepatorenal pouch - anechoic stripe between liver and kidney
probe between L 10-11 ribs - splenorenal pouch - anechoic stripe between spleen and kidney
probe supapubically - anechoic markings around the bladder

28
Q

Diagnostic Peritoneal Lavage

A

introducer needle and 10 cc syringe
1 cm inferior to umbilicus
directed at 60 deg angle inferiorly
advance into peritoneal cavity and aspirate
if no frank blood, place guidewire to lateral gutter
puncture skin with scalpel
advance catheter over guidewire
instill 1L of saline, agitate abdomen, siphon fluid
send for analysis
blunt positive if over 100k RBC / cc
penetrating positive if over 5k RBC / cc

29
Q

dorsal slit for phimosis = inability to retract the foreskin

A

sterilize with iodine, anesthetize with lidocaine
incision line - dorsal midline from coronal sulcus to the tip of foreskin
use hemostat between glans and foreskin
close hemostat, remove it
cut along the length of that tissue
refer for formal circumcision

30
Q

paraphimosis reduction= retracted foreskin acting like torniquet

A

topical anesthetic to paraphimotic foreskin
compress foreskin with pressure
thumbs - glans proximal
index fingers - foreskin distal
bring foreskin fully over glans
last resort - phimotic ring incision by urology

Oral Boards (5 decks)

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