Clinical Skills Mishmash Flashcards
(59 cards)
1
Q
Which is more medial, IJ or carotid?
A
IJ more medial than carotid
2
Q
when placing subclavian CVC, what landmarks do you use?
A
Insert needle where medial and middle thirds of clavicle meet
3
Q
Seldinger technique overview
A
- needle, flash
- remove syringe/occlude needle with finger
- insert guidewire
- remove needle
- Incise skin
- Insert dilator, remove
- insert catheter over guidewire
- remove wire
- aspirate/flush ports
- suture catheter in place
- CXR to confirm
4
Q
MC complication of CVC
A
pneumothorax
also vascular issues, infection, dysrhythmia, nerve injury, other thorax issues, etc.
5
Q
CVC
- pro and con of IJ
A
- Advantages: bleeding easily recognized, rarely malpositioned, less pneumothorax risk, ease of US guidance
- Disadvantages: patient discomfort, risk of carotid artery puncture
6
Q
CVC
- pro and con of subclavian
A
- Advantages: most comfortable for conscious patient, good for hemodynamic measurements (L), lowest infection risk (R)
- Disadvantages: highest risk of pneumothorax, can’t perform on intubated patient, can’t perform if <2 y/o, vein is not compressible
7
Q
CVC
- pro and con of femoral vein
A
- Advantages: easy to locate (NAVEL), 0% chance of pneumothorax, best for emergencies/CPR
- Disadvantages: highest risk of infection, risk of DVT due to immobilization, not good for ambulatory patients
8
Q
LP indications
A
- CNS Infections: meningitis, encephalitis, myelitis
- Inflammatory Processes: MS, Guillain-Barre, vasculitis
- Subarachnoid Hemorrhage: confirmation of suspected acute injury
- CNS Analysis: cytology/specific proteins, malignancy/paraneoplastic syndromes, metabolic conditions
- Therapeutic Needs: to relieve high ICP symptoms, cryptococcus meningitis, idiopathic intracranial hypertension
- Delivery of Meds: anesthesia, chemotherapy, antibiotics, contrast dye for myelogram
9
Q
LP Technique
A
- iliac crest to spinous processes: should be about L4
- betadine and drape
- anesthetic: subcut and then deep as possible
- set up: manometer on stopcock, collection tubes, etc.
- Needle (bevel always to pt’s side) into L3-L4 or L4-L5 space
- “pop” then stop, check for CSF by removing stylet. If none, rotate needle
- Attach manometer, measure opening pressure
- Collect manometer CSF
- Collect CSF from body until get 4 tubes
- Reinsert stylet, ensure bevel is towards pt’s side
- deep inhale and remove
10
Q
LP complications
A
a. Backache: 33% of patients will have this, may be constant or intermittent
b. Headache: 10-30% of patients will have this, worsens with upright/improves with laying flat, beings 24-48 hours after LP and can last up to 2 weeks
c. Transient radicular pain
d. Bleeding: at site of needle insertion, can be due to epidural hematoma development
e. Paraparesis: risk increased with patients on anticoagulation agents
f. Infection/brain herniation (rare)
11
Q
Equipment and materials for MSK injections
A
- betadine/alcohol
- 22 gauge, 1 1/2 inch needle
- corticosteroid
12
Q
Indications for knee joint injection
A
- OA
- other noninfectious inflammatory issues
13
Q
Indications for subacromial joint injections
A
- rotator cuff syndrome
- shoulder impingement
- subacromial bursitis
14
Q
MSK injection: appropriate dose of lidocaine and steroid
A
Small joint (intraphalangeal) - 1/2 ml ea lidocaine and steroid
Medium joint (ankle, wrist, elbow, heel, yes tendon/bursa) - 1 ml ea lidocaine and steroid
Lrg joint (knee, hip, shoulder)
- 1 ml steroid
- 4 ml lidocaine
15
Q
Corticosteroid injections
- pros
A
- inexpensive,
- easy to administer,
- often provide quick and long-lasting relief of pain dt arthritis, tendonitis, bursitis, etc.
16
Q
Corticosteroid injections
- frequency
A
- some disagreement.
- Best rule is no more than every 4 months, max duration 3 years.
17
Q
Corticosteroid injections
- sterile technique
A
inside of joint or tendon sheath is similar to an abscess cavity, poor circulation, easy to grow infections (esp bc cortisone can reduce immune system)
18
Q
Corticosteroid injections
- systemic effects
A
- Very small amount absorbed. DM might experience 1-2 day increase in blood sugar levels
- Others: facial flushing, tachycardia, dysphoria.
- Tx with antihistamine
- Steroid flair: intense burning or aching pain at injection site. Usu 1-2 days but can be severe, consider narcotic pain relief
19
Q
Corticosteroid injections
- MC used
A
kenalog
depo-medrol
20
Q
Corticosteroid injections
- which preparation to use
A
- suspension: should be cloudy or have a chalky end
- NOT solution which is clear as water
21
Q
Indications for knee arthocentesis
A
- Rule out septic arthritis
- Differentiate between gout and pseudogout
- Differentiate between inflammatory and noninflammatory effusions and hemarthroses
- To drain large effusions, hemarthroses
22
Q
Knee arthrocentesis
- procedural steps
A
- patient supine, slight flex to knee
- ID landmark, prep skin
- place sterile drape
- 18 gauge needle
- super 1/3 of patella (medial or lateral), direct towards intercondylar notch
- don’t contact bone with needle
- pull back on plunger as insert needle
- remove as much fluid as possible
23
Q
NG tube insertion
- length of tube
A
- ear to umbilicus
24
Q
NG tube insertion
- confirm in correct place
A
- Inject air and listen over stomach for bubbling
- CXR
25
NG tube
| - types of tube
- straight suction: bigger but more likely to get clogged
| - sump suction: less likely to get sucked against stomach wall and get plugged, smaller lumen so less suction ability
26
Chest tube sizes
- hemopneumothorax: 32-36 french
- simple pneumo: 26-32 French
- stable with isolated pneumonia: 12-20 french
27
Insertion site for chest tube:
- lateral thorax at anterior axillary line
| - tube in 4th or 5th intercostal space (above the bone)
28
Chest tube
| - mateirals
- lots of obvious stuff
- 10 blade
- surgical silk suture size 0
29
Intubation
| - Indications
- CPR airway management
| - Mechanical ventilation (resp failure, general anesthesia, coma)
30
Intubation
| - CI
- massive maxillofacial trauma (relative)
- fractured larynx
- c-spine injury (relative)
31
Anesthesia
- Esters
- Amides
- which MC for allergic rxn
- Amide: lidocaine, bupivocaine, mepivicaine
- Ester: procaine, marcaine, cocaine
-ester more common to cause allergic reactions
32
How to calculate dose of anesthesia medication in mg (formula)
volume (mL) * % concentration * 10
| = dose(mg)
33
Systemic toxicity reaction from anesthetic medication symptoms
```
tongue numbness
lightheadedness
visual disturbances
muscular twitching
unconsciousness
seizures
```
34
when is epinephrine CI?
digital blocks
35
Diamond technique for local anesthetic admin
- Visualize a diamond surround area to be anesthetized
- Inject 2 small wheals at apex of the diamond
- Next, block the 4 sides of the diamond through those wheals
36
Digital block technique
- Numb skin with lidocaine (faster onset)/bupivacaine (longer duration)
- Introduce 25-guage needle at base of finger just below the web space and to the side of the base of the proximal phalanx
- Advance needle until it nearly reaches other side of finger and inject 2-3mL of lidocaine as you withdraw. Redirect before fully withdrawing and inject another 1mL on dorsal part of finger
- Remove needle and repeat procedure on the other side
37
Three types of wound healing
- First intention: wound is closed be routing primary suturing, stapling or gluing. Epithelialization occurs in 24-48 hours
- Secondary intention: wound not closed by suturing, stapling or gluing but closes by spontaneous contraction and epithelialization at rate of 1mm/day. Most often used for wounds that are infected and packed open
- Third intention (aka: delayed primary closure): wound left open for a time and then sutured at later date. Often used with grossly contaminated wounds
38
Absorbable sutures
- ____gut
- Vicryl
- others
39
Nonabsorbable sutures
- Gore-tex
- Nylon/ethilon
- polyester
- polypropylene (polene)
- silk
- stainless steel
40
Suture size for diff body locations
- Face: 5-0 or 6-0 nylon or polypropylene when appearance important
- Scalp: 3-0 nylon or polypropylene
- Trunk/extremities: 4-0 or 5-0 nylon or polypropylene
- Use 3-0 and 4-0 absorbable sutures such as Dexon or Vicryl to approximate deep tissues
41
Types of suture pattern
- simple interrupted
- continuous running
- vertical interrupted mattress (far far near near
- horizontal interrupted mattress: calloused skin like palms and soles
- Subarticular closure:
42
Suture removal
- don't pull dirty suture through skin
- continuous: cut and pull each part out separately
- cut suture close to skin
- thin scissors or 11 blade
43
Punch biopsy
| - Indications
- Diagnostic tool for lesions/dermatoses that extend into deeper dermis
- Removal of small/medium-sized lesions (ex: compound/dermal nevi)
44
Punch biopsy
| - how stretch skin
- perpendicular to tension lines
45
Punch biopsy
| - how to deal with incision
<4 mm: can leave open to heal via secondary intention
>4mm: interrupted sutures on either side of defect
- 4.0 trunk/extremity
- 5.0 on face
46
Punch biopsy
| - when remove sutures
- 7-10 for face
| - 14 for trunk/extremities
47
Shave biopsy
| - indications
- Dermatomes
- Seborrheic keratosis/skin tags
- Nevi (when melanoma not concern)
- Suspected squamous/basal cell carcinoma
- Controlled deep dermal shave biopsy appropriate for lesion considered for melanoma if adequate depth obtained
48
Shave biopsy
| - angel for superficial and saucerization
- superficial: 10
| - saucerization: 45
49
Shave biopsy
| - how to treat lesion
- aluminum chloride
- electrodessication if still bleeding
- sterile petroleum jelly with bandage on all sides
- remove in 24 hours and wash with soap/water, keep applying petroleum jelly for 14 days or until healed
50
Cryotherapy
| - indication
- Treatment of benign/precancerous lesions
- Commonly treated lesions include actinic keratoses, viral warts (HPV/molluscum contagiosum), seborrheic keratoses, skin tags
51
Cyrotherapy
| - technique
- tip 1-1.5 cm from lesion
- spray until 2 mm rim of frost appears
- continue spraying 5-30 seconds depending on lesion
52
Cyrotherapy freeze times
- AK
- SK
- wart
- Skin tag
- AK: 5-20 seconds
- SK: 5-10 seconds
- wart: 10
- skin tag: 5
53
IV - types of catheter
- short/large bore: rapid resuscitation
| - small: admin of fluids, meds, abx. Less likely to obstruct blood flow or cause phlebitis
54
US probes
- curved: abd and OB
- linear: soft tissue, small parts
- Phased array: FAST exam and cardiac, small footprint enlarged
55
US
| - colors
- Black: fluid (hemorrhage, blood, ascites, urine, bile)
- Gray: solid (liver parenchyma, renal cortex, blood clot)
- White: dense solid (diaphragm, renal capsule, blood vessel walls, fat)
56
FAST exam
| - RUQ
- Morrison pouch
- 8th and 11th rib on mid-axillary line
- black between kidney and liver = intraperitoneal fluid
- fluid between outline of kidney and inside = renal hematoma, cysts, etc.
57
FAST exam
| - cardiac
- pericardial effusion
58
FAST exam
| - LUQ
- splenorenal
- 8th and 11th rib on mid or posterior axillary line, aim more posterior than RUQ
- blood around spleen
59
FAST Exam
| - pelvic
- bladder
- free fluid
- Pouch of Douglas in females: collects blood between uterus and rectum
