Procedures

Question 1

Pericardiocentesis

Answer 1

Equipment 18G spinal needle (10cm) Stopcock 20cc Syringe Blind/ECG guided Procedure Attache lead V2 to need and advance to Lt Scapula Tip Aspirate until fluid cavity entered Subxiphoid vs Parasternal vs 4CH views (usually 2 person technique) SX Probe in SX area Insert needle at 45 degree angle towards Lt Scapula Tip Aspirate Syringe ever 1-2cm until fluid drawn back PSLA Probe in PSLA view Insert needle 45 degree angle in plane with probe towards largest pocket Most anterior part of RV is visualized Aspirate Syringe ever 1-2cm until fluid drawn back Closer in proximity to PCE and avoids Liver and Lung 4CH Probe in 4CH view Insert needle 45 degree angle in plane with probe towards largest pocket Aspirate Syringe ever 1-2cm until fluid drawn back Stop if Blood obtained (>20ml easily aspirated = RV) ECG Changes (STE - current of injury) Pulsations felt Complications Dry Tap/Failed Attempt, PTX, Myocardial Injury/puncture, Arrythmia, Liver Injury, Cardiac Arrest

Question 2

Peristonsillar Abscess Drainage

Answer 2

Peritonsillar Abscess 1. Sterile probe cover to an intracavitary probe. 2. Have your patient sitting forward in a comfortable position holding suction in one hand to use as needed for saliva. 3. Carefully place the US Probe toward to the posterior pharynx at area of PTA. 4. topical anesthetic spray which is used for the I&D can be applied for imaging as well. 5. After locating and measuring the abscess, topical anesthetic (benzocaine) was applied to site. 6. Use an 18 gauge needle with 10cc syringe for the I&D. Prior to drainage, approximately ~0.6mm was measured and then cut off of the 18 gauge needle cap and then the cap was placed back onto the needle. 7. This provided a stopping point to prevent the needle from being inserted too deep - avoiding the ~1.69cm depth where we found the carotid. (Note

Question 3

I&D - Needle Aspiration Foreign Body

Answer 3

US to find FB can use needles to localize difficult/Small FB in orthogonal planes. Guide needle to FB at 2-3 points, and then excise to this point

Question 4

paracentesis

Answer 4

Equipment

Question 5

Thoracentesis

Answer 5

sitting on the side of the bed and leaning over the table (during procedure)

Question 6

Central Venous Access

Answer 6

describe it

Question 7

Endotracheal Intubation

Answer 7

Dynamic Visualization - ‘Snowstorm’ Absence of ‘Double Tract/Double Trachea sign’. Bullet Sign (Shadowing posteriorly to ETT) Lung Sliding Bilaterally - if only on Right - ?Rt main stem

Question 8

Lumbar Puncture

Answer 8

Midline and mark the location of the spinous processes in sagital plane Then Mark a spinous processes at the L3/L4 level in the transverse plane. Can count up from the Sacrum. Outside in

Question 9

Peripheral IV Access

Answer 9

Describe it

Question 10

Knee Arthrocentesis

Answer 10

US Guided Joint Aspiration Inferior vs Superior, LAteral vs medial Find biggest pocket with POCUS and aim for that spot Landmarks are inferior to patella with knee in flexion or Suprapatellar Pounch, whichn is superior 1/3 to the PAtella, with knee in extension

Question 11

Hip Athrocentesis

Answer 11

Similar to 3 in 1 or Fasicia illiaca block approach aim for femoral neck or area with biggest pocket of fluid

Question 12

Wrist Athrocentesis

Answer 12

Wrist in mild flexion and ulnar deviation, about 20 degrees Enter wrist just distal to lister’s tubercle on the radius, ulnar to the extensor pollicis longus tendon. (of the 2 thumb tendons seen dorsally, it’s the tendon that’s on the ulnar side) Can do in line approach with Ultrasound visualizing the extensor pollicis tendon, and inserting the Needle directly down adjacent to the probe, protecting the tendon with the probe

Question 13

Ankle Athrocentesis

Answer 13

Midway between medial malleolus and tibialis anterior tendon, over the hollow at the anterior aspect of the malleolus

Question 14

Elbow Athrocentesis

Answer 14

Elbow in flexion, 60 degrees with wrist in pronation Approach laterally, aiming for articulation between humeral epicondyle and ulna.

Question 15

Intrascalene Block

Answer 15

For Shoulder Dislocation https

Question 16

Intercostal Nerve Block

Answer 16

Rib # https

Question 17

Radial/Median/Ulnar Nerve Blocks

Answer 17

for Phalanx #, MCP#, FB

Question 18

Equipment needed for Nerve Block

Answer 18

Ultrasound machine with linear transducer (8-18 MHz), sterile sleeve, and gel Cleaning Agent/Soluprep Standard nerve block tray/Drapes Three 10-mL syringes containing local anesthetic A 1.5-inch, 22- to 25-gauge needle with low-volume extension tubing Sterile gloves

Question 19

Popliteal Sciatic Nerve Block

Answer 19

Ankle # except medial Malleolus Slightly proximal to Trifurcation of PV. Blocks Sciatic Nerve, which branches into Common Peroneal, Tibial Nerve. Also Motor Block - so can’t do if patient needs to ambulate Lateral Approach, not commonly done

Question 20

Posterior Tibial Nerve Block

Answer 20

Posterior Tibial Nerve Block Innervates Heel and Base of Foot FB at base of foot, or plantar laceration usual medial or posterior approach, Cross leg and get them relaxed Approach Proximal and posterior to medial malleolus Needle pointment posteriorly adjacent to posterior tibial vein, posterior tibial artery near Achilles Tendon, FDL, FHL

Question 21

Fascia Illiaca Block vs 3 in 1 block

Answer 21

hip # Femoral Nerve, Obturator Nerve, Lateral Cutaneous Nerve

Question 22

infraorbital Block

Answer 22

Upper Lip

Question 23

Inferior Alveolar Block

Answer 23

Lower Lip, Dental

Question 24

Complications of Nerve Blocks

Answer 24

Complications Neurovascular Injury Peripheral Nerve Injury Infection Compartment Syndrome Bleeding Pneumothorax Intravascular Injection (LAST)

Question 25

Clinical Features and Treatment of LAST

Answer 25

Intravascular Injection (LAST) Local Anesthetic Systemic Toxicity Give with Epinephrine to limit systemic spread Know toxic doses Symptoms Vertigo, Tinnitus, Vomiting Metallic Taste, perioral numbness Seizure, Coma, Death Treatment Supportive Care Intralipid