Arterial catheter placement

This video shows Indications, Allen`s test and Preparation for Arterial catheter placement.

Myringotomy tube insertion

Example of myringotomy and tube placement. Tubes are inserted for chronic are signifcant recurrent ear infections. They typically stay several months to a couple of years. They are intended to ventilate the middle ear space in order to treat as well as prevent future middle ear infections.

CopperT Insertion Animation

All about lumbar puncture procedure

How to perform LP

Why cricothyrotomy is the best site for emergency airway

You witness a choking incident in a restaurant. The Heimlich maneuver is unsuccessful at removing the food from the pharynx. The victim is having extreme difficulty breathing and starts to pass out. Where are you most likely to produce an emergency airway?

• a.In the midline just superior to the hyoid bone
• b.In the midline just inferior to the hyoid bone
• c.At the laryngeal notch
• d.At the junction between the thyroid cartilage and cricoid cartilage
• e.At tracheal ring 2 to 3 below the cricoid cartilage

The answer is (d).

The food is most likely stuck in the laryngeal pharynx, so you must produce an alternative airway below the glottis, which reflexly closes.
Locations around the hyoid bone (answers a and b)and above the laryngeal notch (answer c)are above the blockage and would not get air into the lungs. The isthmus of the thyroid gland
generally lies in front of the second and third tracheal ring (answer e), and because it is so highly vascular, it is not an ideal location for an emergency airway.

An additional alternative location for an emergency airway would be the jugular notch, but is not preferred because of the occurrence of a thyroid ima artery below the isthmus, in a small percentage of the population.

More useful links :

TRACHEOSTOMY,How to do!!

Clinical Complications of Tracheostomy

Common recommended sites for insulin injection

At first insulin recommended to be injected into some sites where a less-sensitive layer of fatty tissue just below the skin to absorb the insulin with no many nerves ,so that insulin injection will be more comfortable in these sites more than others the  just under the skin.
Also these sites make it easier to inject into the subcutaneous tissue, where insulin injection is recommended. 

Common sites for insulin injection are :

A-Abdomen :the most common insulin injection site because it has easily accessible fatty areas and Insulin is absorbed faster when it is injected into the abdomen " So:you should inject the insulin into the abdomen just before meals",Also This area allows for greater access if injecting individually.

Notes:

Do not inject within 1-2 inches around the navel "tissue is tough" ,surgical, other scar tissue, moles.

B-Thighs :The middle and outer thigh area is another one of the common insulin injection sites that are suitable for injecting long-acting insulin.Don't inject too close to the area just above knee because the tissue is very tough.


C-Arms :The back of the upper arm

Nasogastric tube insertion

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Arterial Blood Gases for OSCEs

Procedures to open obstructed airway

#The tongue is the single most common cause of an airway obstruction. In most cases, the airway can be cleared by simply using the head-tilt/chin-lift technique. This action pulls the tongue away from the air passage in the throat ,See this video:

Head tilt chin lift Technique

#The head-tilt/chin-lift is an important procedure in opening the airway; however, use extreme care because excess force in performing this maneuver may cause further spinal injury. In a casualty with a suspected neck injury or severe head trauma, the safest approach to opening the airway is the jaw-thrust technique because in most cases it can be accomplished without extending the neck.See it:

Jaw Thrust Technique

Introduction To Serum Protein Electrophoresis

McMurrays test

McMurray's test is performed with the patient lying flat (non-weight bearing) and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to 90 degrees of flexion.

Umbilical vein catheterization technique

Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation. The umbilical vein remains patent and viable for cannulation until approximately 1 week after birth.
Umbilical vein catheters (UVC), are used for exchange transfusions, monitoring of central venous pressure, and infusion of fluids (when passed through the ductus venosus and near the right atrium); and for emergency vascular access for infusions of fluid, blood products or medications.
Usually in the emergency department peripheral access is preferred for critically ill newborns and if this is impossible, umbilical vein catheterization may be attempted.

Technique :

# The umbilical cord stump and surrounding abdomen should be sterilized with a bactericidal solution. Sterile drapes should be placed.
# A purse-string suture or umbilical tape is tied around the base of the stump to provide hemostasis and to anchor the line after the procedure.

# Using the scalpel, the cord is cut horizontally, approximately 1.5-2 cm from the abdominal wall. Two thick-walled small arteries and one thin-walled larger vein should be identified. The umbilical vein may continue to ooze blood.
# Hemostasis is achieved through tightening the umbilical tape or suture. The arteries do not usually bleed secondary to vasospasm.
# Forceps are then used to clear any thrombi and dilate the vein.
# A 3.5F catheter is used for preterm newborns, and a 5F catheter is used for full-term newborns.

5F umbilical catheter. Note proximal attachment for stopcock

# The catheter should be flushed with pre-heparinized solution and attached to a closed stopcock.
# The catheter is then grasped 1 cm from its distal tip with the iris forceps and gently inserted, aiming the tip toward the right shoulder. Advance the catheter only 1-2 cm beyond the point at which good blood return is obtained. This is approximately 4-5 cm in a full-term neonate. If resistance is initially met, loosen the umbilical tape or suture and manipulate the angle of approach.

Insertion of umbilical vein catheter

# Do not force the advancement.
# Secure the catheter with a suture through the cord, marker tape, and a tape bridge.
# The position of the catheter must be confirmed radiographically. A properly placed umbilical vein catheter appears to travel cephalad until it passes through the ductus venosus.
# Standardized graphs estimate the length of catheter insertion based on shoulder-to-umbilicus length. Alternatively, the shoulder-to-umbilicus length may be multiplied by 0.6 to determine a length that leaves the tip of the catheter above the diaphragm but below the right atrium.
# In an emergency resuscitation, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained.

No anesthesia is typically required for the procedure.

Extraglottis Devices

How to perform Combined Spinal-Epidural Obstetric Anesthesia

Femoral Nerve Block at the level of the inguinal skin crease

Femoral nerve block is commonly performed by insertion of the block needle 1-2 cm lateral to the femoral artery just below the inguinal ligament as seen in the picture which requires multiple attempts at localization of the femoral nerve Performing the block at the level of the inguinal skin crease however, has given us more consistent results in the practice as it gives more superficial position of the femoral artery and nerve, Greater width of the femoral nerve, More consistent femoral nerve-artery relationship.

Steps of of the Technique:

A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery at the level of inguinal crease, a skin fold 3 to 6 cm below and parallel to the inguinal ligament. The needle is slowly advanced at an angle of 60° cephalad to the horizontal plane while seeking a quadriceps muscle twitch (rhythmic movements of the patella).

If a quadericeps muscle twitch is not obtained, the needle is withdrawn and redirected 10° laterally (The Figure below). If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic of choice is injected. However, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10° at a time, and advancing the needle several mm beyond the point at which the sartorius muscle twitch was induced. After injecting 30 ml of local anesthetic the onset of blockade is expected within 3-5 minutes when the current is < 0.4 mA. The block is documented by loss of sensation in the anterio-medial thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.

Transradial Puncture

Foley Catheter

A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Because it can be left in place in the bladder for a period of time, it is also called an indwelling catheter. It is held in place with a balloon at the end, which is filled with sterile water to hold it in place. The urine drains into a bag and can then be taken from an outlet device to be drained. Laboratory tests can be conducted on your urine to look for infection, blood, muscle breakdown, crystals, electrolytes, and kidney function. The procedure to insert a catheter is called catheterization.

A Foley catheter is used with many disorders, procedures, or problems such as these:

1.Retention of urine leading to urinary hesitancy, straining to urinate, decrease in size and force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying
2.Obstruction of the urethra by an anatomical condition that makes it difficult for you to urinate: prostate hypertrophy, prostate cancer, or narrowing of the urethra
3.Urine output monitoring in a critically ill or injured person
4.Collection of a sterile urine specimen for diagnostic purposes
5.Nerve-related bladder dysfunction, such as after spinal trauma (A catheter can be inserted regularly to assist with urination.)
6.Imaging study of the lower urinary tract
7.After surgery

Risks:

-The balloon can break while the catheter is being inserted. In this case, the doctor will remove all the balloon fragments.
-The balloon does not inflate after it is in place. Usually the doctor will check the balloon inflation before inserting the catheter into the urethra. If the balloon still does not inflate after its placement into the bladder, the doctor will then insert another Foley catheter.
-Urine stops flowing into the bag. The doctor will check for correct positioning of the catheter and bag or for obstruction of urine flow within the catheter tube.
-Urine flow is blocked. The doctor will have to change the bag or the Foley catheter or both.
-Patient urethra begins to bleed. The doctor will have to monitor the bleeding.
The Foley catheter may introduce an infection into the bladder. The risk of infection in the urine increases with the number of days the catheter is in place.
-If the balloon is opened before the Foley catheter is completely inserted into the bladder, bleeding, damage and even rupture of the urethra can occur. In some individuals, long-term permanent scarring and strictures of the urethra could occur.

Too see Procedure......

HERE

Vertebroplasty with Procedure Demonstration

What is Vertebroplasty :

The vertebral column or backbone tends to get weak as a person gets old. This is more common in women since female hormones are necessary for normal mineralization. The weak bones in the spine collapse, producing painful fractures. Till a few years ago the only treatment that was available for condition was a major surgery. However thanks to interventional radiology today a fractured bone of the spine can be strengthened by injecting a specialized medical cement ( bone cement) into the diseased vertebral body .

Procedure Demonstration :

Stryker Vertebroplasty uses a specially formulated acrylic bone cement to stabilize and strengthen the fracture and vertebral body. Its done on an outpatient basis and requires only a local anesthetic and mild sedation, eliminating the complications that may result from open surgery and general anesthesia. Stryker Vertebroplasty is considered a minimally invasive procedure because it is done through a small puncture in the patients skin (as opposed to an open incision). Technically simple, it usually takes about 30 minutes to complete.

Using sterile technique and fluoroscopic visualization, a 10-, 11- or 13- gauge needle is advanced into the fractured vertebra using a transpedicular approach. Bi-pedicular needle placement is recommended. Once the needles are in the correct position, bone cement is slowly injected into the vertebral body, diffusing throughout the intertrabecular marrow space and creating an internal cast that stabilizes the bone.

Following the procedure, patients lie flat on their back for a short period of time as the cement continues to harden. They may then go home. Almost all patients undergoing Stryker Vertebroplasty experience 90% or better reduction in pain within 24-48 hours and increased ability to perform daily activities shortly thereafter.

Principles of EndotracheaI Intubation During General Anaesthesia