Procedures & Skills Flashcards
What is most commonly responsible for causing misdiagnosis of pericardial effusion?
Anterior cardiac fat pad
What factors are likely to result in an underestimation of ocular pressure?
- Ocular pressure > 30 mm Hg
- Prior refractive surgery (thin cornea)
- Corneal edema (thick, but soft cornea)
What factors are likely to result in an over estimation of ocular pressure?
- Supine patients
- Breath holding
- Off-center measurement
- Excessively depressing cornea with sensor
Side effect of benzocaine
methemoglobinemia
Equipment needed to perform needle cricothyrotomy
5mL syringe, 3.0 ETT adapter, 16G over-the-needle catheter
Four measures to reduce risk of developing post-LP headache?
- Ensuring needle bevel parallel to dural fibers
- Replacing stylet prior to removing needle
- Small-diameter needles (22 gauge)
- Atraumatic needles (Quincke or Whitacre)
Absolute contraindications to LP
- Plt < 20,000
- Coagulopathies
- INR >/= 1.5
(Can give platelets or clotting factors, reverse anticoagulation) - Lumbar trauma vertebrae
- Infection at puncture site
- Heparin administration in 24 hrs prior
- Spinal or CNS lesion causing increased ICP
Maneuvers for reduction of nursemaid’s elbow (radial head subluxation)
- Supination technique
- Hold elbow at 90 degrees with pressure at radial head
- Firmly supinate child’s wrist and flex elbow directing wrist toward ipsilateral shoulder - Hyperpronation
- Hold elbow at 90 degrees
- Firmly pronate wrist
Best transport solution for avulsed tooth
Hank’s solution - isotonic solutions with glucose and sodium bicarb (Milk is good alternative)
ED care of tooth avulsion
- Temporary replantation
- Tooth should be gently rinsed (not wiped)
- Tooth should be handled by the crown
- Dental socket carefully rinsed and suctioned
- Tooth replanted gently and splinted with periodontal dressing material
- Arrange dental follow-up for following day
Proper procedure for PTA aspiration/I&D
- Premedicate with opioid + intramucosal anesthetic
- Finger sweep to assess for fluctuance
- Needle sheath should be used to control puncture depth
- Aspiration undertaken in the soft palate at the point of maximal abscess fluctuance
- Medial and superior aspiration are safer to avoid carotid artery (2.5 cm posterolateral to tonsil)
Contraindications for PTA needle aspiration
- Severe trismus
- Non-cooperative patient
- Recurrent PTA (indication for tonsillectomy)
- Evidence of deep neck tissue extension
- Airway obstruction
At which location is the pediatric airway the narrowest?
Cricoid
Ways pediatric airway differs from adult airway
- Proportionally smaller larynx that is more anterior and cephalad
- Epiglottis is longer and narrower
- Head, occiput, tongue proportionally larger
- Neck is shorter
- Adenoids larger
- Risk of mainstem higher due to short trachea and bronchus
ETT depth equation
3 x tracheal tube size
OR age/2 + 12
Common adverse effects of massive transfusion
- Thrombocytopenia
- Hypocalcemia
- Hypomagnesemia
- Hypothermia
- Metabolic acidosis
- DIC
What four clinical variables are used to calculate the Assessment of Blood Consumption score to predict the need for massive transfusion?
- Penetrating mechanism of injury
- Positive FAST
- SBP <90
- HR >120
Differentiating between traumatic LP and SAH
Presence of xanthochromia is pathognomonic for SAH
Rate of clearance of RBCs from tube 1 to tube 4 was used, but no longer accurate
Contraindications for Tissue Adhesives
- Wounds under tension
- Complex stellate lesions
- Wounds over joints
- Wounds on mucosal surfaces
- Wounds in hairy areas
- Wounds requiring high level of precision
- Bite wounds
Tissue adhesives are equivalent to what type of sutures?
5-0 Nylon
How long do tissue adhesives typically remain on the wound?
5-10 days
What vein is most preferable to access during a peripheral venous cutdown in children?
Saphenous vein - distal at the medial ankle where it crosses 1cm anteriorly to the medial malleolus
After what period of time does the incidence of infection rise dramatically following insertion of a peripheral catheter?
After about 48 hours
If saphenous nerve damaged during cutdown, what type of deficit will be felt?
Small area along medial aspect of foot with sensory loss
What is a marker of a successful procedure after performing lateral canthotomy and cantholysis?
- Resolution of a previously detected afferent pupillary defect (pupil exhibits consensual, but not ipsilateral pupillary response to a light stimulus)
- Improved visual acuity
- Decrease in IOP to <40 mm Hg
Primary indications for lateral canthotomy
- Decreased visual acuity
- IOP > 40 mm Hg
- Proptosis
Secondary indications for lateral canthotomy and cantholysis
- Afferent pupillary defect
- Cherry red macula
- Ophthalmoplegia
- Nerve head pallor
- Eye pain
Contraindication to lateral canthotomy
Suspected globe rupture
DOPES mnemonic for hypoxia in ventilated patients
D-displacement -> verify tube with end-tidal CO2
O-obstruction -> suction
P-PTX -> CXR/US
E-equipment -> disconnect ventilator, administer breaths through BVM
S-stacked breaths -> disconnect ventilator
Testicular detorsion technique
Medial to lateral rotation of 360 degrees or more
In which space should a thoracentesis be performed?
Greater than or equal to 1 intercostal space below the top of the effusion in the midscapular or posterior axillary line
No needle insertion below 8th intercostal space
Fascia Iliaca Block procedure step by step
- Patient in supine position
- A line drown b/n ASIS and pubic tubercle and divided into thirds
- At border b/n lateral and medial thirds, perpendicular line 2cm in length drawn caudally
- Blunt needle inserted and directed cephalad - target is area just beneath fascia iliaca
- Local anesthetic injected when operator appreciates two distinct “pops”
Indications for fascia iliaca block
Proximal femur fracture
Between which two muscles does the fascia iliaca block occur?
Iliacus and sartorius muscles
Where is the accurate location to make incisions for escharotomy?
Bilateral anterior axillary lines from the clavicles to the lower costal margin through the eschar down to the subcutaneous fat and extend proximally and distally beyond the borders of the eschar. Two incisions should then be connected by one or more transverse incisions
What agents can be used to emulsify or dissolve adherent tar from skin?
Topical antibiotic creams (not ointments) with polyoethylene sorbitan
Indications for nail trephination in subungual hematoma
- Less than 48 hours old
- Not spontaneously draining
- Blood trapped under nail with intact nail folds
- Painful
Post-procedure care: keep clean and dry for 2 days
How should a paracentesis be performed in second- and third-trimester pregnant patients?
Open supraumbilical or US-guided approach
How many weeks are required for maturation of the cystostomy tract after a new suprapubic catheter is placed, limiting replacement of an accidentally removed catheter?
Six weeks
Inaccurate diagnostic studies from IO
- WBC
- Potassium
- Ionized Ca
- AST, ALT
- Blood oxygenation
Absolute contraindications to IO
- Fractured bone or previously penetrated
- Vascular interruption
Why should patients with posterior nasal packs be admitted to a monitored bed?
Posterior packing can cause vagal stimulation with resulting bradycardia and bronchoconstriction
Dental fractures that expose dentin, what should be applied over the site?
Calcium hydroxide
Drugs that can be delivered via ETT (adults)
NAVEL Naloxone Atropine Vasopressin Epinephrine Lidocaine
Drugs that can be delivered via ETT (peds)
LANE Lidocaine Atropine Naloxone Epinephrine
Where is incision made for venous cutdown of greater saphenous vein in ankle?
Anterior and superior to medial malleolus
What nerve runs with the saphenous vein, and if transected, what are the effects?
Saphenous nerve; sensory loss in a small area along medial aspect of the foot
Indications for ED Thoracotomy
Penetrating traumatic cardiac arrest:
- Cardiac arrest at any point with initial vital signs in the field
- BP <50 mm Hg systolic after fluid resuscitation
- Cardiac arrest in the ED
Blunt trauma:
- Cardiac arrest in the ED
Other:
- Suspect air embolism
Which nerve is at risk of being severed during an ED thoracotomy?
Phrenic nerve
Accurate studies from IO line
- Hgb
- pH, pCO2, serum bicarb
- Cl, BUN, Cr, glucose
- Serum drug levels
- Cultures
Inaccurate studies from IO line
- WBC
- Potassium
- Ionized Ca
- AST, ALT
- Blood oxygenation
Signs that confirm accurate placement of IO line
- Aspiration of bone marrow
- Fluid infuses without extrav
- Needle stands alone without support
Which medication may take 20-30 seconds longer to take effect when delivered through IO line than through peripheral IV?
Succinylcholine
