Escolar Documentos
Profissional Documentos
Cultura Documentos
Core Procedures
1. Central Venous line - femoral vein, subclavian vein, internal jugular vein 2. Lumbar puncture 3. Foley catheter 4. Nasogastric tube 5. Intravenous line* 6. Arterial Blood Gas* - radial artery, femoral artery
* These procedures are difficult to simulate on a cadaver.
Additional Procedures
Endotracheal intubation - curved blade, straight blade Digital blocks - fingers, thumb, toes Joint aspiration - knee, elbow, ankle Thoracentesis Arterial lines* - radial artery, femoral artery
* This procedure is difficult to simulate on a cadaver.
General Principles
Know the following: 1. Indications 2. Equipment sizes 3. Level of sterility 4. Anatomy and positioning which makes procedure easiest for operator and patient. 5. Complications and modes of failure. 6. Anesthesia/analgesia
Important Caveat for any procedure with a needle **DO NOT SWING THE NEEDLE **
If you need to redirect needle, withdraw to just under the skin, and redirect.
Otherwise, redirecting by swinging allows the needle tip to act like a knife cutting tissue.
Pediatrics:
- double lumen catheter 4 French for < 10 kg 5 French for > 10 kg
- Needs to be sterile
- Use large drape to keep the wire sterile.
Anesthesia:
Local lidocaine
Lumbar Puncture
Indications:
Evaluate for: - meningitis - subarachnoid hemorrhage - psuedo-tumor cerebri
Lumbar Puncture
Sterile procedure 22 gauge needle Length: - adults 3 inch - young children 1.5 inch - Indicate top of iliac crests with line on skin - Position patient with back in forward flexion (lying on side or sitting up) - Enter skin at or cephalad to line demarcating iliac crest (stay in mid sagital plane)
Lumbar Puncture
Complications: - paresthesias - nerve root injury (rare)
Modes of Failure: - inability to obtain CSF because puncture site over sacrum - inability to obtain CSF because path of needle not in mid-sagital plane - bloody tap
Lumbar Puncture
Anesthesia: - Local lidocaine
Foley Catheter
Indications:
- monitor urinary output - relieve urinary obstruction
Foley Catheter
- Sterile technique - Use 16 or 18 French in adults (larger if hematuria with clots) - Coude catheter for difficult catheterization in males
Females - urethral meatus in midline. Males - anatomic position of penis is erect (catheter passes easier as U than S) Hypospadias - urethra is ventral in midline.
Foley Catheter
Modes of failure:
Foley Catheter
Anesthesia:
Nasogastric tube
Indications: - decompress stomach in bowel obstruction - assess for UGI bleeding
Nasogastric tube
Adults - Use 18 French Babies - 8 or 10 French - tube goes straight back in nasal cavity - tilt head in extension to get around bend at nasopharynx - flex head forward to keep tube out of trachea.
Nasogastric tube
Modes of failure: - Tube curling around in mouth - Tube in trachea
Nasogastric tube
Anesthesia: Problematic. - LET or Lido w Epi or Cocaine in nose
Modes of failure: - inability to hit artery despite feeling pulse. Suggested technique - feel pulse with index and long finger slightly separated -dont push down too hard with proximal finger - keep needle in line of artery - puncture between fingers
Arterial Lines
- Similar to ABG. - 20 gauge IV catheter or Seldinger technique (kits available)
- Radial line kit with enclosed wire obviates need to sterile drape.
Enter thoracic cavity just above a rib rather than just below a rib. Remember the neurovascular bundle is just below the rib. Place chest tubes posterior to pectoralis major in the anterior or mid axillary line.