Procedures Flashcards
What are 4 historical and physical findings that predict difficult laryngoscopy?
• Mallampati score • Thyromental distabce • Prior difficult intubation • Obesity • Difficulty with moving neck LEMON = look, obstruction, mallampati, obesity, neck mobility
What are 4 rescue devices or techniques after one attempt at direct laryngoscopy fails and BVM is not possible?
● LMA ● Bougie ● Video laryngoscopy ● Needle Cricothyroidectomy ● Fiberoptic bronchoscopy ● Surgical airway
What are 2 advantages in using cuffed endotracheal tubes? 2 clinical situations where cuffed is advantageous to non-cuffed?
Advantages:
- Decreased need for tube exchange due to inappropriate sizing
- Reduced air leak
- airway edema
- reduce aspiration
- high vent pressures
5 ways to identify if a patient is intubated correctly without xray?
- Capnography with waveform or colour change
- Chest Rise
- Air entry to both lung fields
- Direct visualization of ETT through the vocal cords
- Misting of the tube
List four items you would need to have if you had to do a needle cricothyroidotomy but didn’t have a commercial kit
● 12 to 18 gauge angiocatheter (12-16 for adolescent, 16-18 for infants/young children)
● 7 mm ID ETT
● 3 cc syringe with plunger removed
● Self-inflating bag
Name 3 landmarks for chest tube insertion.
- 5th intercostal space - between 5th and 6th ribs (nipple line)
- Posterior to the pectoralis muscle
- Anterior to mid axillary line
This is called the triangle of safety
List six complications of chest tube placement.
- Bleeding
- Pulmonary contusion
- Pneumothorax
- Hemothorax
- Infection
- Bronchopleural fistula
- Laceration of visceral organ: liver, spleen, diaphragm, heart
- Subcutaneous emphysema
- Re-expansion pulmonary edema
- Intercostal neuralgia
What are the steps to a thoracotomy (4)?
- Positioning/preparing your equipment and patient
- Disinfect skin & apply sterile drapes
- With scalpel blade #10, skin incision from margin of sternum along the 4th or 5th intercostal space until posterior axillary line
- Take Mayo scissors or sterile trauma shears to cut medially towards sternum along the previous incision (sheering intercostal muscles)
- Insert rib spreader (Finochietto) between ribs with handle towards axilla and open as wide as possible to maximize exposure
- Damage control - pericardotomy, cross-clamp aorta, open cardiac massage
Indications for thoracotomy?
- Penetrating trauma + unstable despite fluids or cardiac arrest < 15 minutes
- Blunt trauma + unstable/loss of vital signs or chest tube output > 20mL/kg blood
- ONLY IF SETTING HAS RESOURCES TO PROVIDE ONGOING CARE
Contra-indications for thoracotomy?
- No signs of life at the scene
- Asystole is presenting rhythm without tamponade
- Prolonged pulselessness > 15 minutes
- Massive non-survivable injuries have occured
What are four complications of casting/ splinting?
- Pressure ulcers
- Contact dermatitis
- Contractures if prolonged or not in position of function
- Neurovascular compromise (compartment syndrome)
- Thermal injury (burns)
An 8 year presents with a foreign body in his ear. You see a bug in the canal.
What is one intervention that can facilitate removal of the bug
Use alcohol, mineral oil or viscous lidocaine
What is one foreign body requiring immediate removal from the ear canal
Button battery
What are 4 predictors of difficult ear canal foreign body removal
i. Glass or sharp edged
ii. Spherical or other that is tightly wedged
iii. Up against tympanic membrane
iv. Penetrating foreign bodies
v. Injury to EAC
5 ways to remove an ear foreign body
- Curette (visualize +/- speculum, pass curette past the FB)
- Forceps (again with speculum + visualization)
- Irrigation (C/I if food material/ bean, or can’t see the TM)
- Day ear hook
- Katz extractor (inflatable balloon at the end)
List ten complications of central venous cannulation.
● Hematoma formation ● Infection ● Air embolus ● Pseudoaneurysm ● Catheter or wire fragment in central circulation ● Accidental cannulation of artery ● Arterial or venous laceration ● Arrhythmia ● Pneumothorax (IJ) / Hemothorax (IJ) ● Pneumomediastinum (IJ) ● Cardiac trauma (IJ) ● Stenosis (long-term) ● Thrombosis ● Fistula
femoral venous catheter - 3 advantages, 3 disadvantages?
Advantages Rapid access with high success rate Does not interfere with CPR Does not interfere with intubation No risk of pneumothorax Trendelenburg position not necessary during insertion
Disadvantages: Delayed circulation of drugs during CPR Prevents patient mobilization Difficult to keep site sterile Difficult for PA catheter insertion Increased risk of iliofemoral thrombosis
You have a 5 yo with a large laceration requiring repair. What are 6 ways to minimize the use of physical restraint?
● Child life ● Local anesthesia ● Procedural sedation ● Topical anesthesia ● Distraction ● General anesthesia ● Talking the child through the procedure
What are 4 indications to physically restrain a patient in the ER?
● Imminent harm to others
● Imminent harm to the patient
● Significant disruption of important treatment or damage to the environment
● Continuation of an effective, ongoing behavior treatment program
What are 4 potential complications of physical restraints in the undifferentiated agitated patient
● circulatory obstruction ● Pressure sores ● Paresthesias ● Rhabdomyolysis ● Unmet fluid and toileting needs
What are four locations that you can place an IO?
Proximal tibia Distal femur Distal tibia Proximal humerus Sternum ASIS
IO contraindications?
- Infection at the site
- Bleeding disorder
- Osteogenesis imperfecta
- Fractured bone
- Previous IO attempt in same bone
IO complications?
- Extravasation of fluids into subcutaneous tissues -> compartment/skin necrosis
- Subcutaneous abscess, osteomyelitis, septicemia
- Physeal injury or fracture
- Fat embolus
- Damage to bone marrow (long-term)
List 2 advantages and disadvantages for nitrous oxide use for analgesia
Advantages:
● Rapid onset, short duration of action
● Provides sedation, dissociation and amnesia
● No major cardiopulmonary events
● Situations where you can’t do local anesthetic
Disadvantages:
● Requires patient cooperation
● Expensive
● Inadequate analgesia for painful procedures
● Can cause N+V, dysphoria
● Bulky equipment, training required, needs scavenger system
What are 4 complications of a femoral nerve block?
● Quadriceps weakness ● Infection ● Arterial or venous puncture ● Nerve injury ● Hematoma ● Local anesthetic systemic toxicity ● Allergic reaction
What are the toxic doses of lidocaine with epinephrine and lidocaine without epinephrine?
7 mg/kg and 4 mg/kg
List 2 tongue lacerations that would require suturing.
- Deep lacerations that are at the lateral or anterior border of the tongue (risk for fork tongue deformity)
- Lacerations > 1cm that are deep to the muscle layers or completely through the tongue
- Large laceration at risk for food entrapment
- Significant hemorrhage that can’t be stopped
4 layers of the scalp
SCALP: skin (sub)Cutaneous tissue Aponeurosis (galea aponeurotica) Loose areolar tissue pericranium
4 ways to close scalp lac (not including suturing)
Skin Tape
Tissue Adhesives (Glue)
Hair apposition technique
Staples
Hair tourniquet - 3 methods for removal
● Blunt metal probe under hair
● Nair
● Cut down to the bone
5 ways to remove a ring
- Ring cutter
- For hard metals (steel or titanium) may need a dental drill
- String pull technique
- String wrapping technique
- Lubricant
- Double penrose technique
- Surgical glove technique
2 situations when you should NOT remove a fishhook.
● No absolute CI
● If near eye, eyelid or vital structures need subspecialist
Describe 2 different ways to remove a fishhook
● barb cut: at site of point entry use 1% lidocaine or digital block; using needle holder and wearing gloves advanced barb part of hook out of skin, cut with wire cutter than remove rest of hook from skin
● string removal: explain procedure, digital block or 1% lidocaine, loop a piece of string around the hook, with dominant hand depress hook against skin and then pull sharply
How to assess pain?
o < 5 years old = can’t report on a scale, relies on observation (different charts exists including Behavioral Pain score, CHEO Pain scale – combination of behavioral and physiologic measurements
o Older: self-report pain scales = gold standard (faces scale, 1-10 scale)
Factors that increase risk of aspiration in sedation?
deep sedation, stomach contents, anesthetic agent used (ie. Higher risk with volatile agents), PPV, hx of GERD
Etomidate - good and bad features?
- Good – short duration, less HD effects, dec ICP
- Bad – myoclonus, adrenal suppression, vomiting
Propofol - good and bad features?
- Good – rapid on/off, antiemetic, amnesia
- Bad – HD effects, narrow therapeutic range, don’t use in egg/soy allergy
Ketamine - good and bad features
- Good – no hypotension (causes HTN), preserved airway reflexes, bronchodilation, analgesia and sedation
- Bad – CV collapse if catecholamine depleted, risk of laryngospasm (treat with PPV and paralysis), recovery agitation, vomiting
Chloral hydrate - disadvantages?
Long duration of action, paradoxical reactions, slow onset
