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EM > Procedures > Flashcards

Procedures Flashcards

1
Q

Needle gauge for arthrocentesis

A

25-27 for anesthetic, then 18-22 for aspiration

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2
Q

What to send joint aspirate for?

A
  • cell count with differential
  • crystals
  • gram stain
  • culture

*protein, glucose, LDH no longer recommended

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3
Q

LP Landmarks (Adults)

A

L2-L3 to L5-S1

PSI Crests are @ L4

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4
Q

LP Landmarks (Infants)

A

Cord goes to L3

L4-L5 or L5-S1

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5
Q

LP Needle gauge + length

A

Adult: 3.5” 20G

Child: 2.5” 22G

Infant: 1.5” 22G

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6
Q

LP Tubes

A

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

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7
Q

LP Normal opening pressures

A

7-20 cm H20

25 cm in obese patients

28 cm in patients <18

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8
Q

LP Bacterial vs. viral CSF

A

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

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9
Q

LP Neurosyphilis Testing

A

**CSF VDRL: **60% sens., very specific

**FTA-ABS CSF: **++ sensitive, ~95% specific

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10
Q

Bartholin’s Drainage

A

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

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11
Q

Landmarks for Paracentesis

A

1) Infraumbilical in the midline through linea alba
2) Lateral rectus - 5 cm cephalad and 5 cm medial to ASIS

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12
Q

How much fluid to remove on paracentesis?

A

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)

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13
Q

When to give albumin (and how much) for paracentesis?

A

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.

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14
Q

When to send out paracentesis fluid and what to send it for?

A

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.

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15
Q

Lab Cutoffs for Peritonitis

A
  • >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
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16
Q

SAAG

A

Serum-Ascites Albumin Gradient

SAAG >1.1 g/dL indicates portal hypertension with >95% accuracy

17
Q

Post-paracentesis Circulatory Dysfunction (PCD)

A

Some think it is myth. Can happen hours to days after. Hypovolemia, hyponatremia, renal dysfunction.

18
Q

Insertion Depth for Right Subclavian CVC

A

(Height/10) - 2 cm

178 cm = 15 cm

19
Q

Insertion Depth for Left Subclavian CVC

A

(Height/10) + 2 cm

178 cm = 20 cm

20
Q

Insertion Depth Right IJ CVC

A

Height/10

178 cm = 17 cm

21
Q

Insertion Depth Left IJ CVC

A

(Height/10) + 4 cm

178 cm = 22 cm

22
Q

Landmarks for IJ Insertion

A

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.

23
Q

Landmarks for Subclavian Line Insertion

A

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.

24
Q

Femoral Vein Landmarks

A

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.

25
Q

IO Needle Sizes

A
  • 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

26
Q

IO Flow Rates

A
  • Proximal Humerus: ~5 L/h
  • Prox Tibia: ~1 L/h
  • Both with 300 mm Hg pressure bag*
27
Q

IO Site Care

A
  • 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
28
Q

IO Lidocaine Flush Dosing

A

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

29
Q

IO Insertion Landmarks

A

Review on Evernote “IO”

30
Q

IO Contraindications & Risks

A

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
31
Q

Intercostal Nerve Block

A

Review on Evernote

32
Q

Wrist Blocks

A

Review on Evernote

33
Q

Femoral Nerve Block

A

Review on Evernote

34
Q

Posterior Tibial Nerve Block

A

Review on Evernote “Ankle Blocks”

35
Q

Thoracentesis

A

Evernote

36
Q

Pneumothorax management

A
  • 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
  • secondary pneumo (pre-existing lung disease or trauma)
    • admit
    • probably all need chest tubes
      • Keflex/Ancef x 24-48 h

EM (27 decks)

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