Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter !' + Practical Proced,res Cha"ter !' Practical Proced,res P-..% (sing this cha"ter This cha"ter describes those "ractical "roced,res that the /,nior doctor or senior n,rse may be ex"ected to "erform Ob)io,sly, some of these are more com"licated than others012and some sho,ld only be "erformed once yo, ha)e been trained s"ecifically in the correct techni3,e by a more senior colleag,e

Each "roced,re has a diffic,lty icon as follo4s:

o

5e3,ires no s"ecific f,rther training and all medical grad,ates sho,ld be com"etent to "erform5e3,ires some skill- 6octors in their %nd year after grad,ating sho,ld be able to "erform 4ith easeMore com"lex "roced,res 4hich yo, may only come across in s"ecialty /obs and 4ill not be re3,ired to "erform 4itho,t s"ecific g,idance from seniors-

5,les are made to be broken 7ery many "roced,res and "ractical skills do not ha)e a 018correct019 method b,t ha)e an 018acce"ted019 method These methods sho,ld, therefore, be abided by b,t de)iation from the ro,tine by a com"etent "ractitioner, 4hen circ,mstances demand is acce"table

Many "roced,res ha)e local )ariations012if in do,bt, yo, sho,ld check the standard method that is ,sed in yo,r hos"ital or tr,st-

:nfiltrating anaesthetic agents ; large n,mber of "roced,res in)ol)e the infiltration of local anaesthetic agents- :t is im"ortant that yo, deli)er these safely012in/ection of a large amo,nt of anaesthetic into a )ein co,ld lead to "otentially fatal cardiac arrhythmias- :t is also im"ortant, of co,rse, to ens,re that yo, do not damage any )essels;d)ance and 4ithdra4 <hene)er yo, in/ect anything, yo, sho,ld ad)ance the needle and attem"t to 4ithdra4 the "l,nger at each ste"+if yo, do not as"irate blood, yo, may then go ahead and infiltrate the anaesthetic-

Making a s,rface bleb Take the syringe of anaesthetic =e-g- !> lidocaine? and a small needle Pinch a "ortion of skin, insert the needle hori@ontally into the s,rface

<ithdra4, as abo)e, and in/ect a small amo,nt of the anaesthetic012yo, sho,ld see a 4heal of fl,id riseThe area of skin 4ill no4 be s,fficiently anaestheti@ed to allo4 yo, to infiltrate dee"er-

P-..A P-..B terility and "re"aration Most e3,i"ment 4ill come in "re+"acked sterile 4ra""ing- <hen "erforming a "roced,re 4here sterility is im"ortant, all "ackaging sho,ld be o"ened ,sing a 018no+to,ch019 techni3,eCarge 018"acks019 of e3,i"ment ome e3,i"ment is a)ailable in "re+"re"ared sterile 018"acks019- Dor exam"le, a 018catheteri@ation "ack019 contains ga,@e, cotton balls and a sterile "ot- These come 4ra""ed in sterile tiss,e "a"er;ny s,ch "acks sho,ld be "laced on a trolley 4hich has first been cleaned 4ith antise"tic sol,tion- Eo, sho,ld then caref,lly o"en the "ack o,t, to,ching the corners only012and ,sing glo)ed handsThe o"ened "ack can then be ,sed as a sterile s,rface on 4hich to "lace additional sterile e3,i"mentmaller "ieces of e3,i"ment Most e3,i"ment =e-g- needles, syringes? comes sterili@ed and 4ra""ed in "a"erF"lastic- These sho,ld also be o"ened ,sing a no+to,ch techni3,e if absol,te sterility is neededDor exam"le, ,n4ra" a needle by "eeling back the "ackaging as if "eeling a banana and allo4 the needle to dro" onto the "re+"re"ared sterile s,rfaceP-... P-..G

Hand 4ashing Theory Hand 4ashing is the single most im"ortant "roced,re for "re)enting the s"read of infections- :t is ,nder"erformed in terms of fre3,ency and 3,ality- Hands sho,ld be 4ashed before e)ery e"isode of care that in)ol)es direct contact 4ith a "atientHs skin, their food, in)asi)e de)ices, or dressings, and after any acti)ity or contact that "otentially res,lts in hands becoming contaminated-

;lcohol handr,b sho,ld also be reg,larly ,sed 4hen entering or lea)ing a 4ard and before and after examining "atientsE3,i"ment oa"Falcohol gel 6is"osable "a"er to4els

Moist,ri@er =if re3,ired?-

Proced,re :f hands are not )isibly soiled, hand hygiene 4ith alcohol is as, if not more, effecti)e than hand4ashing<hen re3,ired to 4ash o,r hands 4e sho,ld ,se soa" and 4arm 4ater- Those "arts often missed are the ti"s of fingers, th,mbs, and bet4een the fingersThe follo4ing ro,tine is ad)ised in most tr,sts =Dig- !'-!?: Dirst, r,b hands "alm to "alm =Dig- !'-!a? 5,b right "alm o)er the left dors,m

5,b left "alm o)er the right dors,m<ash "alm to "alm 4ith the fingers interlaced =Dig- !'-!b?<ash the backs of the fingers 4ith o""osing "alms 4ith fingers interlocked =Dig- !'-!c?Perform rotational r,bbing of the right th,mb clas"ed 4ith the left fist =Dig- !'-!d?Perform rotational r,bbing of the left th,mb clas"ed 4ith the right fist<ash the right "alm 4ith rotational r,bbing ,sing the fingers of the left hand<ash the left "alm 4ith rotational r,bbing ,sing the finger of the right hand =Dig- !'-!e?<ash the s"ace bet4een the th,mbs and first fingers by interlocking them and r,bbing together =Dig- !'-!f?5inse a4ay all soa" and "at dry ,sing dis"osable "a"er to4els;""ly moist,ri@er to "rotect the skin from the drying effects of reg,lar 4ashing-

0IJ Hints Kee" nails short, clean and "olish free ;)oid 4earing 4rist 4atches and /e4ellery, es"ecially rings 4ith ridges or stones

;ny c,ts or abrasions sho,ld be co)ered 4ith 4ater+"roof dressing-

P-..'

Dig- !'-! The correct stages of hand 4ashing as described o""osite<e thank Cyn 6ean for her assistance 4ith this to"icP-..L

:n/ections Theory This is an im"ortant and ro,tine "roced,re 4hich is often carried o,t by n,rsing staff, altho,gh doctors may be asked to administer medication at times- Mood in/ection techni3,e can make the ex"erience for the "atient relati)ely "ainless- Three commonly ,sed ro,tes of administration are s,bc,taneo,s = FC?, intram,sc,lar =:M? and intradermal =:6?E3,i"ment yringe =si@e de"ends on in/ection? Needles: %.+ga,ge for FC ro,te; %!+%A+ga,ge for :M ro,te

Extra %!+g,age needle for dra4ing ," dose;lcohol s4ab-

Mlo)esCotton 4oolhar"s binMedication for in/ecting-

Proced,res ,bc,taneo,s in/ections The FC ro,te is ,sed for a slo4 absor"tion of medication and is ideal for dr,gs s,ch as ins,lin :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent <ash yo,r hands and ",t on a "air of glo)es

0IJ ;l4ays check yo, ha)e the correct dr,g, correct dose, and that it is 4ithin date before in/ecting it6ra4 ," the medication ,sing a %!+ga,ge needle and ha)e a colleag,e do,ble check the medication, dose, and ex"iry dateEx"el any air in the syringe and re"lace 4ith a %.+ga,ge needleClean the in/ection site 4ith the alcohol s4abPinch a fold of skin so as to lift the adi"ose tiss,e a4ay from the ,nderlying m,scle:nsert the needle hori@ontally into the fold and dra4 back to ens,re yo, are not in a )einNo4 in/ect the medication<ithdra4 the needle and a""ly the cotton 4ool to the site to mo" ," any bleeding,itable FC sites incl,de the forearm, trice"s area, and abdomen-

:ntram,sc,lar in/ections :M in/ections are administered thro,gh the e"idermis, dermis, and FC tiss,e into the m,scleThey "ro)ide ra"id systemic action and allo4 relati)ely large doses to be absorbed,itable :M sites incl,de the deltoid m,scle, dorsogl,teal site, )entrogl,teal site, lateral thighF)ast,s lateralis, 3,adrice"s m,scle, and the rect,s femoris m,scle5emember to a)oid sites of inflammation, s4elling, infection, or skin lesionsP-..O

:ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent<ash yo,r hands and ",t on a "air of glo)es-

0IJ ;l4ays check yo, ha)e the correct dr,g, correct dose and that it is 4ithin date before in/ecting it6ra4 ," the medication ,sing a %!+ga,ge needle and ha)e a colleag,e do,ble check the medication, dose, and ex"iry dateEx"el any air in the syringe and re"lace 4ith a %.+ga,ge needle:ns"ect the "ro"osed site for ade3,ate m,scle massClean the in/ection site 4ith the alcohol s4ab:M in/ections sho,ld be gi)en at a O&#P angle to ens,re the needle reaches the m,scle, and to 0QR "ain; good 4ay to ens,re acc,racy and a)oid a needle+stick in/,ry is to rest the heel of the "alm on the th,mb of the non+dominant handP,ll the skin do4n4ards or to one side at the intended siteHold the syringe bet4een the th,mb and forefinger and insert the needle at f,ll de"th6ra4 back on the syringe to ens,re the needle is not in a )einlo4ly in/ect the medication;fter needle insertion and in/ection allo4 !& seconds before remo)ing the needle to facilitate diff,sion of the medication into the m,scle<ithdra4 the needle and 4i"e the area clean 4ith cotton 4ool-

:ntradermal in/ections The :6 ro,te "ro)ides a local, rather than systemic effect and is ,sed "rimarily for diagnostic ",r"oses s,ch as allergy or t,berc,lin testingThis in)ol)es the same "reliminary 4ork+," abo)e exce"t a %.+ga,ge needle is inserted at a !&+ !.#P angle, be)el ,", /,st ,nder the e"idermis(" to &-.ml is in/ected ,ntil a 4heal a""ears on the skin s,rface+/,st as yo, 4o,ld 4hen creating a bleb of local anaesthetic<e thank Cyn 6ean for her assistance 4ith this to"icP-.G&

7ene",nct,re T4o methods exist, the 018traditional019 needle+and+syringe and the ne4er method of collecting blood directly into the t,bes by 7ac,tainer#SE3,i"ment 01T Mlo)es 01T ticky ta"e 01T ;lcohol s4abs 01T Ma,@eFcotton 4ool

01T To,rni3,et 01T ; needle =try !%M first?, a syringe and blood collection bottle or01U; 01T ; 7ac,tainer#S t,be, holder and blood collection needleProced,re (sing a needle and syringe :ntrod,ce yo,rself, confirm "atientHs identity, ex"lain the "roced,re, and obtain )erbal consent The "atient sho,ld be lying or sitting comfortably 4ith the arm from 4hich blood is to be taken resting on a "illo4

elect a )ein site012,s,ally the antec,bital fossa =see Dig- !'-%?;""ly the to,rni3,et "roximal to the ",nct,re site and recheck the )einP,t on glo)es and ask the "atient to clench their fist a fe4 timesCleanse the area 4ith an alcohol s4ab in s"irals, inside to o,t-V ;ttach the needle to a syringe and ,nsheathe it(se the th,mb of yo,r non+dominant hand to gently anchor the skin /,st belo4 the ",nct,re site<arn the "atient to ex"ect a 018shar" scratch019 and to not mo)e their arm:nsert the needle firmly thro,gh the skin, be)el ,"4ards, at an angle of %&+B&#S o)er the )ein<ith ex"erience, yo, 4ill feel a slight 018gi)e019 as the )ein is entered and blood 4ill )isibly enter the h,b ="lastic "ortion? of the needle =018flashback019?Caref,lly holding the needle in "osition, ",ll back on the "l,nger- There are se)eral 4ays of doing this, the a,thors fa)o,r holding the needle and syringe in the non+dominant hand, once in "lace, and ",lling back 4ith the dominant hand<hen eno,gh blood is taken, release the to,rni3,et before remo)ing the needle from the )ein;""ly a clean cotton 4ool ball or folded ga,@e to the ",nct,re site as the needle is 4ithdra4n- Press,re sho,ld be a""lied for W!min- =ask the "atient to do this for yo,, if they are able?;""ly a "laster to the site, thank the "atient7ac,,m blood t,bes are filled by ",nct,ring the r,bber to" 4ith the needle and allo4ing the blood to enter the t,be5emember to label the t,bes correctly012ideally at the "atientHs bedside and dis"ose of shar"s in a shar"s bin-

P-.G!

Dig- !'-% 5e"resentation of "eri"heral )eins of the ,""er limbV There is no solid e)idence for benefit in ,sing alcohol 4i"es ,nless there is )isible dirt at the )ene",nt,re site- Ho4e)er, their ,se is 018"olicy019 in most health care tr,sts and sho,ld be ,sed accordinglyP-.G% (sing a 7ac,tainer#S system M,ch of the "roced,re is the same01U 7ac,tainer#S needles are do,ble+ended, one 018standard019 needle and one needle co)ered by a r,bber slee)e ;ttach a 7ac,tainer#S holder o)er the co)ered needle =see Dig- !'-A?

The needle is inserted into the )ein as abo)e b,t no 018flashback019 4ill be )isibleOnce in "lace, the 7ac,tainer#S t,bes are attached to the needle directly by ",shing them onto the co)ered needle ,sing the t,be holder;llo4 eno,gh blood to enter t,be =some t,bes m,st be filledcheck local laboratory g,idance?M,lti"le t,bes may be filled by remo)ing and re"lacing t,bes 4hilst caref,lly holding the needle in "osition-

:na""ro"riate sites for )ene",nt,re Oedemato,s areas Cell,litic areas

HaematomasPhlebitis or thrombo"hlebitiscarred areas;rm in 4hich there is a transf,sion or inf,sion;rm on the side of "re)io,s mastectomy;rms 4ith ;7 fist,lae or )asc,lar grafts:f extraction of blood 4ith 7ac,tainers is "ro)ing diffic,lt, it may be easier to s4itch to the needle+and+syringe techni3,e as this allo4s yo, more control o)er the flo4 of blood7ene",nct,re can be "erformed at any "eri"heral )ein+diffic,lt to bleed "atients in hos"ital often ha)e blood taken from the back of their hands, feet or legs:n diffic,lt to reach "laces, it is often easier to ,se a 018b,tterfly019 needle- This is a smaller needle attached to a length of t,bing 4hich can be ,sed 4ith either techni3,e- :t allo4s for greater control of the needle-

Hints

Dig- !'-A 7ac,tainer#S blood collection system, ready for ,seP-.GA Xox !'-! Taking blood from a central )eno,s catheter Theory Central lines sho,ld only be ,sed for taking blood if it is not "ossible to obtain a sam"le )ia the "eri"heral ro,te- 6o not risk catheter se"sis or a clotted line ,nless there are no alternati)esY

E3,i"ment A Z[ !&ml syringes &-O> isotonic or he"arini@ed saline

Chlorhexidine s"ray or iodineMa,@eterile glo)es6ra"e-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent to" any inf,sions for at least one min,te before sam"ling

Place the "atient in a s,"ine "osition;sk the "atient to t,rn their head a4ay from the line site d,ring the "roced,re6ra"e the site in case of s"lash and ",t on a "air of sterile glo)es"ray the line chosen to 4ithdra4 blood 4ith chlorhexidine sol,tionEo, may alternati)ely ,se a ga,@e di""ed in iodine sol,tionClam" the line before remo)ing the ca"Connect a !&ml syringe to the line before ,nclam"ing<ithdra4 .+!&ml of blood, clam" the line and remo)e the syringe6iscard the bloodConnect a ne4 !&ml syringe to the line, ,nclam" it and 4ithdra4 a f,ther !&ml of bloodClam" the line, remo)e the syringe =kee" this sam"le?Dill a f,rther syring 4ith saline and attach to the line(nclam" the line, instill the saline, and clam" the line again5emo)e the syringe and re"lace the ca"-

P-.GB

Peri"heral :7 cann,lation Theory

Peri"heral :7 cann,lation is a 018generic019 skill that the medical st,dent sho,ld learn early- ; thin t,be 018line019 is inserted into a )ein allo4ing easy )eno,s access 4hich is ,sed in many sit,ations, incl,ding the administration of fl,ids and i) medicationE3,i"ment Mlo)es ;lcohol s4abs

To,rni3,etaline for in/ection.ml syringeticky ta"eMa,@eFcotton 4ool; cann,la of a""ro"riate si@e-

Proced,re :ntrod,ce yo,rself, confirm "atientHs identity, ex"lain the "roced,re, and obtain )erbal consent The "atient sho,ld be lying or sitting comfortably 4ith the arm in 4hich the cann,la is to be inserted resting on a "illo4

;""ly the to,rni3,et to the arm and identify a s,itable )ein =often those that can be felt are more reliable than those that are seen?- The )ein sho,ld be s,"erficial and ha)e a straight co,rse for a fe4 centimetersP,t on the glo)es and clean the o)erlying skin 4ith the alcohol s4ab5emo)e the cann,la from its "ackagingEns,re that the cann,la is f,nctioning "ro"erly by slightly 4ithdra4ing the needle and re"lacing it- Dold do4n the 0184ings019 and o"en and close the "ort on the to"<arn the "atient to ex"ect a 018shar" scratch019 and to not mo)e their arm:nsert the cann,la firmly thro,gh the skin, be)el ,"4ards, at an angle of %&+B&#P o)er the )ein<ith ex"erience, yo, 4ill feel a slight 018gi)e019 as the )ein is entered and blood 4ill )isibly enter the h,b ="lastic "ortion? of the cann,la =018flashback019?Once the flashback is seen, hold the needle in "lace 4ith one hand and slide the cann,la off the needle012into the )ein0124ith the other- Once the cann,la is f,lly inserted, the needle sho,ld be sitting /,st 4ithin it, "re)enting blood from s"illing5elease the to,rni3,et-

Press o)er the )ein at the ti" of the cann,la, remo)e the needle, and dis"ose of it safely in a shar"s binP,t the ca" on the cann,la and fix it in "lace 4ith the sticky dressing6ra4 ," the saline into the syringe and 018fl,sh019 it thro,gh the cann,la ,sing the "ort on the to"- <atch the )ein012if the cann,la is mis"laced, the saline 4ill enter the s,bc,taneo,s tiss,es ca,sing s4elling0IJ 6onHt forget to do this012it confirms that the cann,la is 4orking and clears it of blood 4hich 4o,ld form a clot-

P-.G. Xox !'-% i@ing cann,lae Cike needles, cann,lae are colo,r+coded according to si@e- Each is gi)en a 018ga,ge019 4hich has an in)erse correlation to the external diameterThe standard si@e cann,lae is 018green019 or !LM b,t for most hos"ital "atients, a 018"ink019 or %&M cann,la 4ill s,ffice- E)en bl,e cann,lae are ade3,ate in most circ,mstances ,nless fast flo4s of fl,id are re3,iredGauge External Length Approximate Colour diameter (mm) maximum flow (mm) rate (mL/min) !BM %-! B. %O& Orange !GM !-' B. !'% Mrey !LM !-A B. 'G Mreen %&M !-& AA .B Pink %%M &-L %. %. Xl,e

Dig- !'-B ; selection of standard :7 cann,lae-

Hints

Try to a)oid the antec,bital fossa- ;ltho,gh this is often the easiest "lace to see and feel a )ein, cann,lae at that site can become kinked and blocked 4hilst ca,sing "ain for the "atient on bending the arm;)oid an arm 4ith a fist,la or ;7 sh,ntXring a selection of different si@ed cann,lae to the bedside allo4ing yo, to choose a smaller ga,ge if yo, ex"erience "roblems6onHt be afraid to ask for assistance from n,rsing or a,xiliary staff if the "atient is likely to mo)e their arm d,ring the "roced,re-

P-.GG

etting ," an inf,sion Theory Dl,id thera"y is one of the basic res"onsibilities of /,nior doctors and one of the core skills for n,rses- <hilst it is ,s,ally the /ob of the n,rsing staff to set ," the dri", /,nior medical staff sho,ld ne)ertheless be com"etent at this techni3,eE3,i"ment Mlo)es ;n a""ro"riate fl,id bag

Mi)ing set6ri" stand-

Proced,re

:7 inf,sions re3,ire :7 access012see "-.GB- Check the fl,id in the bag and fl,id "rescri"tion chart;sk a colleag,e to do,ble+check the "rescri"tion and the fl,id and sign their name on the chartO"en the fl,id bag and gi)ing set, 4hich come in sterile "ackaging(n4ind the gi)ing set and close the ad/,stable )al)e5emo)e the sterile co)er from the bag o,tlet and from the shar" end of the gi)ing set =see Dig- !'-.?(sing 3,ite a lot of force, ",sh the gi)ing set end into the bag o,tlet:n)ert the bag, hang on a stand3,ee@e the dri" chamber to half fill it 4ith fl,id-

Partially o"en the )al)e to allo4 the dri" to r,n, and 4atch fl,id r,n thro,gh to the end =it might be best to hold the free end o)er a sink in case of s"ills?:f b,bbles a""ear, try ta""ing or flicking the t,beOnce the gi)ing set is filled 4ith li3,id, connect it to the cann,la;d/,st the )al)e and 4atch the dri"s in the chamber;d/,st the dri" rate according to the "rescri"tion =see Table !'-!?-

<e thank Cyn 6ean for her assistance 4ith this to"icP-.G'

Dig- !'-. 6iagrammatic re"resentation of the base of a fl,id bag and the "ort in 4hich the gi)ing set sho,ld be insertedXox !'-A 6ri" rate Most inf,sions tend to be gi)en 4ith electronic de)ices 4hich ",m" the fl,id in at the "rescribed rate- Ho4e)er, it is still im"ortant that health care "rofessionals are able to set ," a dri" at the correct flo4 rate man,ally(sing a standard gi)ing set, clear fl,ids 4ill form dri"s of abo,t &-&.ml012that is, there 4ill be a""roximately %& dri"sFml- Eo, can then calc,late the n,mber of dri"s "er min,te for a gi)en inf,sion rate as belo4Table 17.1 nfu!ion and drip rate! "re!#ription nfu!ion rate nfu!ion rate%rip rate $umber of hour!(ml/hour) (ml/minute) (drip!/minute) per litre of fluid ! !&&& !G A%& % .&& L !G&

B G L !& !% %B P-.GL

.& !GG !%. !&& LA B%

B A % !-G !-B &-'

L& G& B& A% %L !B

External /,g,lar )ein cann,lation Theory The external /,g,lar )ein lies s,"erficially in the neck, r,nning do4n from the angle of the /a4, across the sternocleidomastoid m,scle before "assing dee" to drain into the s,bcla)ian )ein- :t is sometimes ,sed to "ro)ide essential )eno,s access in cardiac arrest and other emergency sit,ations 4here no "eri"heral access is obtainableee Dig- !'-G for the s,rface anatomy of the external /,g,lar )einE3,i"ment ;ntise"tic sol,tionFantise"tic 4i"e % Z[ .ml syringes

! %.+ga,ge orange needle! %!+ga,ge green needle!> lidocaine!B+ or !G+ga,ge cann,la&-O> saline fl,sh6ressingMlo)eshar"s bin-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re and obtain )erbal consent if "ossible <ash yo,r hands and don a "air of glo)es

Tilt the "atient to !&+!.#P head+do4n to facilitate )eno,s fillingOnce the external /,g,lar )ein is )isible, clean the area 4ith antise"tic sol,tion-

;ttach a %.+ga,ge =orange? needle to a .ml syringe and make a FC bleb of !+%ml of !> lidocaine and infiltrate aro,nd the insertion siteinto the )einXe caref,l not insert any anaesthetic

Position yo,rself at the head of the bed5emo)e the ca" from the cann,la and attach a clean .ml syringeT,rn the "atientHs head a4ay from the side of insertionCann,late ,sing the same techni3,e as for "eri"heral )eno,s access0IJ 5emember to as"irate as yo, ad)ance the cann,la- Correct "lacement 4ill be confirmed once yo, are able to as"irate )eno,s bloodDix the cann,la in "lace ,sing a s,itable dressingDl,sh the cann,la 4ith .ml of &-O> saline sol,tion6is"ose of all shar"s in shar"s bin, 4ash hands and hel" the "atient to a comfortable "osition6oc,ment details of "roced,re in notes-

Hints :n an emergency sit,ation, yo, may forgo the anaesthetic as )eno,s access may be needed s4iftlyP-.GO P-.'&

Central )eno,s cann,lation Theory Central )eno,s access is the "lacement of a catheter in a )ein 4hich leads directly to the heartThere are a n,mber of central )eins incl,ding the internal /,g,lar, external /,g,lar, s,bcla)ian, femoral, and antec,bitalDor each of these, the basic e3,i"ment and "re"aration are the same- Central )eno,s cann,lation is "erformed for )asc,lar access, TPN, inf,sion of irritant, )asoacti)e, and inotro"ic dr,gs, meas,rement of C7P, cardiac catheteri@ation, ",lmonary artery catheteri@ation, trans)eno,s cardiac "acing, and haemodialysisF"lasma"horesisingle and m,lti+l,men catheters are a)ailable and the ty"e to be ,sed sho,ld be decided "rior to insertion de"ending on the antici"ated ,se =e-g- conc,rrent C7P monitoring and m,lti"le dr,g inf,sion?E3,i"ment Trolley-

terile "ack incl,ding sterile dra"esterile go4n and glo)es,t,re material e-g-+%F& silk on a c,r)ed needle;ntise"tic sol,tionCocal anaesthetic+a""rox .ml of !> lidocaineeldinger central )eno,s line kit%!+ga,ge green and %.+ga,ge orange needlesaline or he"arini@ed saline to "rime and fl,sh the line "rior to and "ost insertionterile dressing(ltraso,nd machine-

Proced,re012internal /,g,lar )ein :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent 5emember, this can be a "otentially frightening "roced,re- Ex"lanations and reass,rance m,st be gi)en before and d,ring the "roced,re

P,t on a sterile go4n and glo)es(n4ra" all e3,i"mentCheck that the 4ire "asses thro,gh the needle freely- ;ttach A+4ay ta"s to all "orts of the catheter- Dl,sh all the l,mens 4ith he"arini@ed salinePlace the "atient in a s,"ine "osition, at least !.#P head do4no

This is ,s,ally 3,ite easy on a tilting bed and is "erformed to distend the neck )eins and red,ce the risk of air embolism-

T,rn the head a4ay from the )ene",nct,re siteCleanse the skin 4ith antise"tic sol,tion and dra"e the areatand at the head of the bedCocate the cricoid cartilage and "al"ate the carotid artery lateral to itThe site for insertion is a""roximately !FA of the 4ay ," the sternocleidomastoid, /,st bet4een its % heads(se local anaesthetic to n,mb the )ene",nct,re site once located-

P-.'!

:nfiltrate the skin and dee"er tiss,es 4ith a smaller orange needle and then re"lace 4ith a green needle:ntrod,ce the large calibre introd,cer needle, attached to an em"ty syringe, into the centre of a triangle formed by the % lo4er heads of the sternocleidomastoid m,scle and cla)icleKee" yo,r finger on the carotid artery and ens,re the needle enters the skin lateral to the artery6irect the needle ca,dally at an angle of A&+B&#P to the skin, to4ards the i"silateral ni""le- The )ein is ,s,ally 4ithin %+Acm of the skin;s"irate as the needle is ad)anced- Once yo, see blood, cann,late the )ein ,sing the eldinger techni3,e 01U 5emo)e the syringe, occl,de the needle l,men 4ith a th,mbtraighten the J ti" of the s"ring g,ide4ire, and ad)ance into the )essel thro,gh the needleHolding the s"ring+4ire in "lace, remo)e the needle 4hilst maintaining a firm gri" on the 4ire at all timesEnlarge the c,taneo,s ",nct,re site 4ith the c,tting edge of the scal"el "ositioned a4ay from the s"ring+4ire g,ide(se the dilator "ro)ided to enlarge the site and thread the ti" of the catheter into the )essel ,sing the s"ring+4ire g,ideMras" the catheter near the skin and ,sing a slight t4isting motion ad)ance into the )einMake s,re that before yo, ",sh the catheter for4ard the 4ire is )isible at the "roximal end- Hold the 4ire at all times, to "re)ent it being lost inside the "atientHold the catheter and remo)e the s"ring+4ire g,ideCheck l,men "lacement by as"irating thro,gh the "igtails and fl,sh 4ith salineCock off the A+4ay ta"s- The "atient can no4 be le)elledec,re the catheter in "lace 4ith a s,t,re and co)er 4ith an adhesi)e sterile dressing- =6o not forget to anaestheti@e s,t,re sites as 4ell?5e3,est a C\5 to )erify correct catheter "osition and to excl,de a "ne,mothoraxo

Catheters ha)e a radio+o"a3,e stri" for this ",r"ose-

The catheter ti" sho,ld lie in the 7C at the le)el of the carina-

6is"ose of yo,r shar"s and clear a4ay the trolley6oc,ment the details of the "roced,re in the notes-

Com"lications of internal /,g,lar )ein cann,lation Pne,mothorax Haemothorax

Chylothorax;ir embolism;rrhythmaisCarotid artery ",nct,re:nfectionThrombosis of )esselNe,ral in/,ryCardiac tam"onade;7 fist,laPatient discomfort-

M,idelines "rod,ced by the National :nstit,te for Clinical Excellence =N:CE? in e"tember %&&% enco,rage the ro,tine ,se of %+6 =X+mode? ,ltraso,nd g,idance for C7C insertion into the :nternal /,g,lar )ein in ad,lts and children in electi)e and emergency sit,ations- There is ho4e)er, limited e)idence s,""orting ,ltraso,nd ,se for s,bcla)ian and femoral )ein cann,lation- (ltrasonogra"hy allo4s direct )is,ali@ation of the anatomy before and d,ring cann,lation- Portable ,ltraso,nd machines can be ,sed at the bedside- This is not disc,ssed hereP-.'% Proced,re: femoral )ein The femoral )ein lies medial to the femoral artery immediately beneath the ing,inal ligament- :t is commonly ,sed in an :C( setting for "lacement of a do,ble+l,men haemofiltration line and 4hen central access is ,nfeasible by other ro,tes- This is im"ractical for mobile "atients and raises concerns regarding the sterility of the groin area :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain consent Extend the "atientHs leg and abd,ct slightly at the hi"

;do"t f,ll ase"sis-

Cocate the femoral artery, kee" a finger on the artery, and introd,ce a needle attached to a !&ml syringe at B.#P, !-.cm medial to the femoral artery ",lsation, %cm belo4 the ing,inal ligamentlo4ly ad)ance the needle ce"halad and "osteriorly 4hilst gently 4ithdra4ing the "l,nger<hen a free flo4 of blood a""ears, follo4 the eldinger a""roach as detailed for the internal /,g,lar )ein(ltraso,nd can be ,sed to identify the )essels and ens,re that the )ein is ",nct,red near the ing,inal ligament 4here the artery and )ein lie side by side-

Proced,re: s,bcla)ian )ein The s,bcla)ian )ein is "referred for central )eno,s access if the "atient has a cer)ical s"ine in/,ry and is best for long+term "arenteral n,trition, "acing 4ires, or Hickman lines- :t is, ho4e)er, associated 4ith a higher incidence of incorrect line "lacement than internal /,g,lar cann,lation- 6,e to the local anatomy, "ress,re cannot be exerted on the s,bcla)ian artery if it is accidentally ",nct,redThe s,bcla)ian )ein is a contin,ation of the axillary )ein and r,ns from the a"ex of the axilla, behind the "osterior border of the cla)icle and across the first rib to /oin the internal /,g,lar )ein, forming the brachioce"halic )ein behind the sternocla)ic,lar /oint :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Place the "atient in a s,"ine "osition, head+do4n

T,rn the head to the contralateral side;do"t f,ll ase"sis:ntrod,ce a needle attached to a !&ml syringe, !cm belo4 the /,nction of the medial !FA and o,ter %FA of the cla)icle6irect the needle medially, slightly ce"halad, and "osteriorly behind the cla)icle to4ard the s,"rasternal notchlo4ly ad)ance the needle 4hile gently 4ithdra4ing the "l,nger<hen a free flo4 of blood a""ears, follo4 the eldinger a""roach as detailed earlierThe catheter ti" sho,ld lie in the 7C abo)e the "ericardial reflectionPerform a C\5 to confirm the "osition and excl,de a "ne,mothorax;s before, ,ltraso,nd can be ,sed to g,ide ",nct,re of the )ein ,sing a more lateral a""roach-

P-.'A

5emo)ing internal /,g,lar )eno,s catheters 5emo)e any dressing and s,t,re material Ens,re that all dr,gs and inf,sions ha)e been sto""ed

Cie the "atient do4n to red,ce the risk of air embolism;sk the "atient to take a dee" breath and f,lly exhale5emo)e the line smoothly 4ith a steady ",ll, 4hile the "atient is breath holding and a""ly firm "ress,re to the ",nct,re site for at least . min,tes to sto" bleedingit the "atient ,":f infection is s,s"ected, send the ti" of the line in a dry s"ecimen "ot for c,lt,re-

Dig- !'-G The s,rface anatomy of the internal /,g,lar )ein =a? and s,bcla)ian )ein =b?P-.'B

Xlood "ress,re meas,rement

Theory XP is meas,red 4ith a s"hygmomanometer =s"hyg?012,s,ally at the brachial arteryMachines, o"erated by n,rses or health care assistants ,s,ally meas,re XP these days b,t these are not fool+"roof and a good 4orking kno4ledge of the 018man,al019 method of XP meas,ring is still essential; c,ff is a""lied to the ,""er arm and inflated so as to c,t off the arterial s,""ly- The "ress,re is released slo4ly and a stethosco"e ,sed to listen for the blood flo4- <hen the "ress,re in the c,ff e3,als the systolic blood "ress,re, blood 4ill a,dibly ",lse thro,gh the artery- <hen the c,ff "ress,re falls belo4 the diastolic blood "ress,re, the blood 4ill flo4 contin,o,sly and the so,nd of intermittent blood flo4 4ill disa""earE3,i"ment ; =f,nctioning? s"hygmomanometer 4ith 01U ;n a""ro"riately si@ed c,ff =see Table !'-%?

tethosco"e-

Proced,re :ntrod,ce yo,rself, ex"lain the "roced,re, and obtain )erbal consent Check the s"hyg is 4orking and the dial reads 018&019

The "atient sho,ld be sitting, relaxed for . min,tes beforehand;""ly the c,ff to the ,""er arm 4ith the air bladder anteriorly =o)er the brachial artery?(sing yo,r left arm, s,""ort the "atientHs arm so that it is held hori@ontally at the le)el of the mid+stern,mClose the )al)e =may be a scre4 or le)er?, monitor the "atientHs radial artery, and inflate the c,ff ,ntil the radial ",lse is no longer "al"ableCisten o)er the brachial artery at the antec,bital fossa012,sing the dia"hragm or the bell of the stethosco"e0124hilst deflating the c,ff at a rate of %+AmmHgFsecNote the "oint at 4hich the ",lsation is a,dible =KorotkoffV "hase :012the systolic XP?01U ;nd the "oint at 4hich the so,nds disa""ear =Korotkoff "hase 7012the diastolic XP?5ecord the XP as 018systolicFdiastolic019 to the nearest %mmHg-

0IJ Hints :n some normal "eo"le, the so,nds may not disa""ear com"letely- :n this case, a distinct m,ffling of the noise =Korotkoff "hase :7? sho,ld be ,sed to indicate the diastolic XP XP recording may be "artic,larly diffic,lt in a noisy hos"ital 4ard at the time of an emergency =4hich is 4hen doctors are most often asked to record the XP? or 4hen the XP is )ery lo4- :n this case, a ro,gh estimation of the systolic XP may be made by feeling for the ret,rn of the radial ",lse as the c,ff is deflatedP-.'.

Table 17.& '() guideline! for #hoi#e of '" #uff ndi#ation *idthLength'ladder Arm #ir#um+feren#e (#m) (#m) (#m) dimen!ion! (#m) mall ad,ltFchild!&+!% !L+%B !%Z[!L ]%A tandard ad,lt !%+!A %A+A. !%Z[%G ]AA Carge ad,lt !%+!G A.+B& !%Z[B& ].& ;d,lt thigh c,ff %& B% ].% P-.'G

5ecording a !%+lead ECM Theory The ECM is a recording of the electrical acti)ity of the heart- Electrodes are "laced on the limbs and chest for a 018!%+lead019 recording- The term 018!%+lead019 relates to the n,mber of directions that the electrical acti)ity is recorded from and is not the n,mber of electrical 4ires attached to the "atientY E3,i"ment ;n ECM machine ca"able of recording !% leads !& ECM leads =B limb leads, G chest leads?+sho,ld be attached to machine

Cond,cting sticky "ads =018ECM stickers019?-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Position the "atient so that they are sitting or lying comfortably 4ith their ,""er body, 4rists, and ankles ex"osed

Each electrode is attached by cli""ing it to the sticky "ads and sticking them to the "atientHs skinThe leads are ,s,ally labelled- The limb leads are often colo,r+codedo o o o

5ight arm012redCeft arm012yello45ight leg012greenCeft leg012black-

The arm leads are of medi,m length and sho,ld be attached to a hairless "art of the "atientHs 4rists-

The leg leads and longest are sho,ld be attached to the "atientHs ankles =the hairless "art /,st s,"erior to the lateral malleol,s is ideal?Position the chest leads as belo4 =see Dig- !'-'?o o o o o o

7!012Bth intercostal s"ace at the right sternal border7%012Bth intercostal s"ace at the left sternal border7A012mid4ay bet4een 7% and 7B7B012.th intercostal s"ace in the mid+cla)ic,lar line on the left7.012left anterior axillary line, le)el 4ith 7B7G012left mid+axillary line, le)el 4ith 7B-

T,rn on the ECM machine- These are ,s,ally self+ex"lanatory re3,ire /,st ! b,tton to be "ressed012marked 018analyse019 or 018record019Check the calibration and "a"er s"eed:
o o

!m7 sho,ld ca,se a )ertical deflection of !&mmPa"er s"eed sho,ld be %.mmFs =. large s3,ares "er second?-

Ens,re the "atientHs name, 6OX, as 4ell as the date and time of the recording are clearly recorded on the trace5emo)e the leads, discard the sticky electrode "ads-

P-.'' 0IJ Hints Enco,rage the "atient to relax as m,scle contraction 4ill ca,se interference Ens,re that yo, cleanse the area gently 4ith an alcohol s4ab before attaching an electrode to ens,re a good connection

The ;C mains electricity may ca,se interference- :f this is the case, try t,rning off the fl,orescent lights-

Dig- !'-' Correct "ositioning of the electrodes for a standard !%+lead ECMP-.'L

;rterial blood gas sam"ling Theory ;n arterial sam"le is obtained to assess "H, PO%, PCO%, HCO+A and base excessFdeficitometimes also ,sed for ra"id assessment of electrolytesE3,i"ment ;XM kit =,s,ally contains he"arin+filled syringe, needle and )ented ca"? Ma,@e or cotton ball

Ta"eterile glo)es-

Proced,re <ash hands and ",t on glo)es 7erify "atient identity, ex"lain "roced,re, and obtain )erbal consent- Xe s,re to 4arn the "atient of "otential "ain and ask them to kee" as still as "ossible

Note "atientHs tem"erat,re and oxygen s,""ortChose site for arterial ",nct,re-

5adial =No ad/acent ner)es or )essels so is the most commonly ,sed site-? ;ssess for ade3,ate ,lnar arterial circ,lation by obstr,cting the radial artery 4ith finger+ ti" "ress,re ;sk the "atient to make a tight fist, ex"elling blood from hand, maintaining "ress,re on radial artery

;sk them to o"en their hand and 4atch for fl,shing of the "alm- This indicates ade3,ate "erf,sionTake the blood gas syringe, ens,ring that the he"arin has coated the inside by 4ithdra4ing and ad)ancing "l,nger;ttach the needle and ex"el the excess he"arinPosition the 4rist in extensionPal"ate the radial arterial ",lse along its length ,sing the middle and index fingersClean the skinHa)ing chosen a s,itable s"ot, insert the needle 4ith the be)el facing to4ards the direction of blood+flo4, ,sing an a""ro"riate angle;d)ance the needle ,ntil arterial "ress,re fills the syringeObtain a sam"le of !+Aml and 4ithdra4 the needle;""ly "ress,re to the ",nct,re site ,sing ga,@e or cotton ball ,ntil bleeding has sto""ed =minim,m % min,tes?5emo)e and discard the needle 4ith care and "lace a )ented ca" on the syringe- Holding )ertically, ex"el any air thro,gh the )entMix sam"le gently and take to a blood gas analyser-

Demoral Position the "atient 4ith the hi" extended and slightly internally rotated Note that the femoral ner)e is /,st lateral to the artery so maintain a medial a""roachP-.'O

Proced,re as abo)e b,t ,se a %!+ga,ge needle, aiming at the ",lsation "ositioned bet4een yo,r index and middle finger-

Xrachial

Position the elbo4 in extension<atch for ad/acent ner)es =see belo4?-

;""ro"riate angles for needle insertion 5adial artery012B.#P Xrachial artery012G&#P

Demoral artery012O&#PThe key to s,ccess is caref,lly lining ," the needle o)er a "al"able ",lsation012take yo,r timeY :f there is no flash+back, 4ithdra4 the needle slightly, change the angle and ad)anceNote that most "ain is from ",nct,ring the skin so do not remo)e needle f,lly 4hen re"ositioning:f there 4ill be some delay in analy@ing the sam"le, store the bloodfilled syringe on iceo,rces of blood gas res,lt errors:
o o o o o

Hints

;ir in the sam"le6elay in analy@ing sam"le or delay in icingExcess he"arin in the syringe;ccidentally obtaining a )eno,s or mixed arterio+)eno,s sam"le;lterations in tem"erat,re-

Dig- !'-L Position of the brachial artery and s,rro,nding str,ct,res at the antec,bital fossa- 5ight arm is "ict,red-

P-.L&

Peak flo4 meas,rement Theory D,ll name 018"eak ex"iratory flo4 rate019 =PED5? is a meas,re of the maxim,m s"eed of ex"iration- Ex"ressed in 018litresFmin,te019, is a sim"le and easy to administer test 4hich is a ,sef,l indicator of air4ay calibre and may be "erformed before and after the administration of a bronchodilator to assess re)ersible air4ay obstr,ctionNormal )al,es are based on gender, age, and heightE3,i"ment ; "eak flo4 meter =see Dig- !'-O? ; clean dis"osable mo,th+"ieceProced,re :ntrod,ce yo,rself, ex"lain the "roced,re, and obtain )erbal consent The "atient sho,ld be standing or sitting ,"right

Ens,re that the meter is set to 018&019;sk the "atient to take a dee" breath in, hold the mo,th"iece in the mo,th, and seal their li"s tightly aro,nd itThe "atient sho,ld blo4 o,t as hard and as fast as "ossible0IJ The PED5 needs a hard and short maximal blo4 o,t- The "atient does not ha)e to blo4 o,t com"letelyMake a note of the reading achie)edThe "roced,re sho,ld be re"eated and the best of A efforts recordedThe res,lt sho,ld be com"ared to the 018normal019 )al,e on the N,nn+Mreggs Nomogram =see OHCMG, "-!GO?-

:f the "atient is to kee" a record, be s,re to ex"lain ho4 to record the readings a""ro"riately- = ometimes a %+4eek diary is ke"t by the "atient to assess for di,rnal )ariation?-

0IJ Hints :f the "atient is ha)ing diffic,lty "erforming correctly, a brief demonstration often "ro)es )ery ,sef,l :f a "atient has )ery )ariable flo4 meas,rements, re"eat yo,r demonstration and go on asking for flo4s ,ntil A consistent readings ha)e been recordedP-.L!

Dig- !'-O ; standard "eak flo4 meter ,sing the E( scale, ado"ted in %&&.P-.L%

:nhaler techni3,e ; "erson ne4 to res"iratory medicine may be s,r"rised by the sheer n,mber of different inhaler de)ices on the market- Each has its ad)antages and disad)antages and a different set of dr,gs that it can deli)erOn these "ages, 4e o,tline the inhaler de)ices c,rrently a)ailable and the instr,ctions for ,se 4ritten as yo, 4o,ld ex"lain them to a "atient- The a,thors s,ggest that st,dents and res"iratory n,rse s"ecialists become familiar 4ith the different de)ices by asking yo,r 4ard "harmacist if yo, can see "lacebo )ersions6e)ices are constantly changing- ;t the time of 4riting, the follo4ing inhalers are 018o,t of fashion019 and are not described here: Clickhaler, "inhaler, ;erohaler, 6iskhaler, 5otahaler, Doradil inhaler, P,l)inal- <e do, ho4e)er, incl,de the 018Handihaler019 4hich is a relati)e ne4comerMetered dose inhaler This 4as the first de)ice and is the one "eo"le think of as a 018ty"ical019 inhaler- :t is small, chea", and has many different dr,gs and doses- Ho4e)er, there is no dose co,nter and re3,ires a good deal of coordination to ,se correctly012making it ,ns,itable for the )ery yo,ng, elderly, or those 4ith arthritis or other ailments affecting the hands:nstr,ctions for ,se Take one dose at a time 5emo)e the ca" and shake the inhaler se)eral times

it ,"right, hold head ," and breathe o,t-

Place inhaler in mo,th and seal li"s aro,nd mo,th"ieceXreath in, "ress the canister do4n to release the dr,g and contin,e to take a dee" breath in- =The canister sho,ld be "ressed /,st after the start of inhalation, not before?5emo)e inhaler and hold breath for as long as "ossible ," to !& seconds5eco)er before taking the next dose, re"lace ca"-

Dig- !'-!& ; metered dose inhaler =M6:?012"ict,red is a alb,tamol inhalerP-.LA ;,tohaler This is one of the 018breath+act,ated019 inhalers, releasing a dose of the dr,g 4hen a breath is taken- This eliminates the need for hand coordination and can reass,re "atients that a dose has been s,ccessf,lly administeredome "eo"le, ho4e)er, may still find the "riming le)er hard to ,se or may ha)e diffic,ltly remembering to "rime the de)ice for each dose- ;lso, the ",ff and click d,ring inhalation can be distracting:nstr,ctions for ,se 5emo)e ca" and shake inhaler se)eral times Prime the de)ice012",sh the le)er right ,", kee"ing the inhaler ,"right

it ,"right, hold head ," and breathe o,teal li"s aro,nd mo,th"iece:nhale slo4ly and dee"ly012donHt sto" 4hen the inhaler clicks and contin,e taking a really dee" breath5emo)e inhaler and hold breath for as long as "ossible ," to !& seconds-

P,sh le)er do4n and re"lace ca"5eco)er before taking the next dose=5emember to ad)ise the "atient, they 4onHt feel the s"ray hitting the back of the throat012altho,gh there may be a slight taste dist,rbance?-

Dig- !'-!! ;,tohaler- Note the le)er on the to"- 5emember that the inhaler m,st be "rimed for each dose0IJ Hints Patients ,nable to ",sh the le)er ," by hand can sometimes ,se the edge of a table to ",sh it against Patients sho,ld breathe in steadily, not as fast as "ossibleP-.LB Easibreathe This is a breath+act,ated inhaler, like the ;,tohaler on the "re)io,s "age- ;gain, there is no need for hand coordination and no le)er on to" of the de)ice- :nstead, the inhaler is "rimed by o"ening the ca"ome "eo"le 4ill, ho4e)er, still find it diffic,lt to "rime the de)ice012and may forget that the ca" m,st be closed and o"ened bet4een each s,ccessi)e dose:nstr,ctions for ,se hake the inhaler se)eral times Hold the de)ice ,"right and "rime by o"ening the ca"

it ,"right, hold head ," and breathe o,teal li"s aro,nd mo,th"iece and be caref,l not to block the air holes on to" 4ith yo,r hands-

:nhale slo4ly and dee"ly- 6onHt sto" 4hen the inhaler ",ffs5emo)e inhaler and hold breath for as long as "ossible ," to !& secondsClose the ca", 4ith the inhaler ,"right5eco)er before taking the next dose=5emember to ad)ise the "atient, they 4onHt feel the s"ray hitting the back of the throat012altho,gh there may be a slight taste dist,rbance?-

Dig- !'-!% Easibreathe- Note the air holes on the to" 4hich sho,ld not be blocked by yo,r hand 4hen taking a doseHint ;d)ise the "atient not to dismantle the inhaler- ome "eo"le are "rone to taking the to" off and ,sing like an M6:Y P-.L. ;cc,haler This is one of the 018dry+"o4der019 de)ices and has s,"erseded the 6iskhaler and the 5otahaler- Cike most of the other inhalers, it is "reloaded and has an integral ca"- :t also has a dose co,nter- Ho4e)er, it is more ex"ensi)e than some of the other de)ices and has se)eral+ste" "riming mechanism that some may not be able to co"e 4ith:nstr,ctions for ,se Hold the o,ter casing and ",sh the th,mb gri" a4ay from yo,, ex"osing the mo,th"iece, ,ntil yo, hear a click Holding the mo,th"iece to4ards yo,, slide the le)er back ,ntil it clicks =the de)ice is no4 "rimed and the dose+co,nter mo)es on one?-

it ,"right, hold head ," and breathe o,tHolding the ;cc,haler le)er, seal li"s aro,nd mo,th"iece:nhale dee"ly and steadily5emo)e inhaler and hold breath for as long as "ossible ," to secondsTo close, slide th,mbgri" to4ards yo,, so that the co)er mo)es o)er the mo,th"iece, ,ntil yo, hear a click5eco)er before taking the next dose=5emember to ad)ise the "atient, they 4onHt feel the s"ray hitting the back of the throat012altho,gh there may be a slight taste dist,rbance?-

Dig- !'-!A ;cc,haler close and o"en- Note the th,mbgri", le)er and mo,th"ieceP-.LG T,rbohaler ;nother dry "o4der de)ice 4ith "reloaded, tasteless dr,g- There is no dose co,nter, b,t a 4indo4 that t,rns red after %& doses012the de)ice is em"ty 4hen there is red at the bottom of the 4indo4- ome "eo"le find the lack of taste disad)antageo,s =they like to be s,re the dose has been gi)en? and, again, those 4ith hand diseases or deformities may find it diffic,lt to ,se:nstr,ctions for ,se (nscre4 and remo)e the 4hite co)er Hold the inhaler ,"right

T4ist the gri" clock4ise then anticlock4ise as far as it 4ill go ,ntil a click is heardit ,"right, hold head ," and breathe o,teal li"s aro,nd mo,th"iece-

:nhale slo4ly and as dee"ly as "ossible5emo)e the inhaler and hold breath for !& seconds5e"lace co)er5eco)er before taking the next dose=5emember to ad)ise the "atient, they 4onHt feel the s"ray hitting the back of the throat012altho,gh there may be a slight taste dist,rbance?NX There are de)ices a)ailable 4hich can calc,late 4hether a "erson has a s,fficient ins"iratory flo4 rate to deli)er the dr,g into the air4ays-

Dig- !'-!B T,rbohaler- Note the tiny dose+indicating 4indo4P-.L' Handihaler ;t the time of 4riting, this is relati)ely ne4 to the market and only a)ailable for tiotro"i,m- :t is a dry+"o4der de)ice 4ith an integrated ca" and re3,ires a lo4er ins"iratory flo4 rate than other de)ices- Ho4e)er, it is not "reloaded, re3,iring a dose to be inserted )ia a ca"s,le at each ,se re3,iring some dexterity- ome "eo"le also find the ca" rather hard to o"en as it re3,ires a moderate amo,nt of strength to get right:nstr,ctions for ,se O"en ca" by ",lling ,"4ards ex"osing mo,th"iece O"en the mo,th"iece by ",lling ,"4ards ex"osing the chamber

Take a ca"s,le from the blister+"ack and insert it into the chamber-

5e"lace the mo,th"iece =make s,re it clicks? and lea)e ca" o"enPress the side b,tton in a fe4 times to "ierce the ca"s,le =yo, can 4atch thro,gh the small 4indo4?it ,"right, hold head ," and breathe o,teal li"s aro,nd mo,th"ieceXreathe in dee"ly to a f,ll breath =yo, sho,ld hear the ca"s,le )ibrate?5emo)e inhaler and hold breath for as long as is comfortableXreathe o,t slo4ly5emo)e the ,se ca"s,le and re"lace the ca"-

Dig- !'-!. Handihaler- Note the b,tton at the side for "iercing the ca"s,le and the small 4indo4 at the frontP-.LL "acer de)ices These are ,sed 4ith a standard M6: and allo4 the dr,g to be ",ffed into a chamber before it is inhaled- This red,ces de"osition of the dr,g in the ,""er air4ays =and the local side effects? and increases "eri"heral l,ng des"osition- This also means that no coordination is re3,ired and the "atient has more time to inhale the dr,g- These are "artic,larly ,sef,l for the )ery yo,ng, elderly, or those 4ith se)ere breathlessness-

These de)ices are, ho4e)er, rather b,lky 4hich "atients may find embarrassing- They do also re3,ire a certain amo,nt of dexterity to ",t togetherThere are a n,mber of de)ices a)ailable b,t it is ex"ected that, d,ring the life of this edition, all 4ill be re"laced by the ;erochamber- <e 4ill, therefore, only disc,ss this de)ice:nstr,ctions for ,se =;erochamber? 5emo)e ca" of the M6:, shake the inhaler and insert into the back of the ;erochamber Xreathe o,t

eal li"s aro,nd mo,th"iecePress do4n the canister once to release the dr,gXreathe in slo4ly and dee"ly012the ;erochamber 4ill 4histle if yo, breathe too 3,icklyHold breath for !& secondsXreathe o,t thro,gh the mo,th"iece and breathe in again =do not "ress the canister a second time?- This may be re"eated ," to B or . breaths:f a second dose is re3,ired, relax for a min,te and then re"eat ste"s A+.5emo)er the inhaler and re"lace the ca"-

Cleaning the ;erochamber The de)ice m,st be rinsed daily in soa"y 4ater ;llo4 to air+dry on drainer012do not r,b =creates static electricity?

;erochambers sho,ld be re"laced by a ne4 model e)ery G months-

P-.LO

Dig- !'-!G ;erochamber4ith M6: inserted in the end<e thank Jeremy 5obson for his hel" in the constr,ction of the 018:nhaler techni3,e019 "agesP-.O&

Oxygen administration Theory This is the administration of s,""lementary oxygen 4hen tiss,e oxygenation is im"airedThe aim is to achie)e ade3,ate tiss,e oxygenation =4itho,t ca,sing a significant 0Q^ in )entilation and conse3,ent hy"erca"nia or oxygen toxicity? 4hile minimi@ing cardio",lmonary 4ork0IJ Oxygen is a dr,g 4ith a correct dosage and side effects 4hich 4hen administered correctly may be life sa)ingThe "rimary res"onsibility for oxygen "rescri"tion at the time of 4riting lies 4ith the hos"ital medical staff- :t is good "ractice to record: <hether deli)ery is contin,o,s or intermittent Dlo4 rateF"ercentage ,sed

<hat aO% sho,ld be-

<hen to treat Tiss,e hy"oxia is diffic,lt to recogni@e as clinical feat,res are non+s"ecific012incl,de altered mental state, dys"noea, cyanosis, tachy"noea, arrhythmias, and coma Treatment of tiss,e hy"oxia sho,ld correct any arterial hy"oxaemia =cardio",lmonary defectFsh,nt e-g- PE, "ne,monia, asthma?, any trans"ort deficit =anaemia, lo4 cardiac o,t",t?, and the ,nderlying ca,ses

0IJ 5emember aO%FPaO% can be normal 4hen tiss,e hy"oxia is ca,sed by lo4 cardiac o,t",t states-

E3,i"ment ee "-.O%Proced,re Ex"lain 4hat is ha""ening to the "atient and ask their "ermission Chose an a""ro"riate oxygen deli)ery de)ice =see next "age?

Chose an initial dose 01U

o o o

Cardiac or res"iratory arrest: !&&>Hy"oxaemia 4ith PaCO% ] .-AkPa: B&+G&>Hy"oxaemia 4ith PaCO% * .-AkPa: %B> initially-

6ecide on the acce"table le)el of aO% or PaO% and titrate oxygen accordingly:f "ossible, try to meas,re a PaO% in room air "rior to gi)ing s,""lementary oxygen=This is not absol,tely necessary es"ecially if the "atient is in se)ere res"iratory distressFhy"oxaemic-? Ciaise 4ith n,rsing staff, "hysiothera"ist or o,treach for s,""ort in setting ," e3,i"ment;""ly the oxygen and monitor )ia oximetry = aO%? andFor re"eat ;XMs =PaO%? in A& min,tes:f hy"oxaemia contin,es, then the "atient may re3,ire res"iratory s,""ort either in)asi)ely or non+in)asi)ely012liaise 4ith yo,r seniors andFor the res"iratory doctorsP-.O!

to" s,""lementary oxygen 4hen tiss,e hy"oxia or arterial hy"oxaemia has resol)edOnly !&> of "atients 4ith COP6 are s,sce"tible to CO% retention 4ith oxygen thera"y(se )ent,ri style masks and monitor closelyThink abo,t 4hat is 018normal019 for the indi)id,al-

Hints

P-.O% Oxygen administration e3,i"ment The method of deli)ery 4ill de"end on the ty"e and se)erity of res"iratory fail,re, breathing "attern, res"iratory rate, risk of CO% retention, need for h,midification and "atient com"liance-

Each oxygen deli)ery de)ice com"rises an oxygen s,""ly, flo4 rate, t,bing, interface #_ h,midification- =H,midification sho,ld be ,sed for "atient comfort, "resence of thick tenacio,s secretions, or for flo4s *BCFmin-? Nasal cann,lae These direct oxygen )ia % short "rongs ," the nasal "assage They: Can be ,sed for long "eriods of time Pre)ent rebreathing

Can be ,sed d,ring eating and talking-

Cocal irritation, dermatitis and nose bleeding may occ,r and rates of abo)e BCFmin sho,ld not be ,sed ro,tinelyCo4 flo4 oxygen masks These deli)er oxygen concentrations that )ary de"ending on the "atientHs min,te )ol,me- ;t these lo4 flo4 rates there may be some rebreathing of exhaled gases =they are not s,fficiently ex"elled from the mask?Dixed "erformance masks These achie)e a constant concentration of oxygen inde"endent of the "atientHs min,te )ol,meThe masks contain 018)ent,ri019 barrels 4here relati)ely lo4 rates of oxygen are forced thro,gh a narro4 orifice "rod,cing a greater flo4 rate 4hich dra4s in a constant "ro"ortion of room air thro,gh se)eral ga"sPartial and non+rebreathe masks Masks s,ch as this ha)e a 018reser)oir019 bag that is filled 4ith ",re oxygen and de"end on a system of )al)es 4hich "re)ent mixing of exhaled gases 4ith the incoming oxygenThe concentration of oxygen deli)ered is set by the oxygen flo4 rateHigh+flo4 oxygen Masks or nasal "rongs that generate flo4s of .&+!%&CFmin ,sing a high flo4 reg,lator to entrain air and oxygen at s"ecific concentrations:t is highly acc,rate as deli)ered flo4 rates 4ill match a high res"iratory rate in "atients 4ith res"iratory distress- :t sho,ld al4ays be ,sed 4ith h,midification<e thank Heidi 5idsdale for her hel" in "re"aring this to"icP-.OA

Dig- !'-!' =a? Nasal cann,lae- =b? Co4 flo4F)ariable concentration mask- =c? Non+rebreath mask=d? Mask 4ith )ent,ri )al)e attached- =e? election of )ent,ri )al)es- =f? H,midification circ,itP-.OB

Xasic air4ay management Theory ;n inade3,ate air4ay leads ra"idly to hy"oxaemia and, if ,ncorrected, brain damage and deathEndotracheal int,bation remains the 018gold standard019 for sec,ring an air4ay and "rotecting the "atient from as"iration-

;ir4ay management 4itho,t int,bation is an im"ortant skill to master and consists of the ,se of one or more of the follo4ing; tri"le manoe,)re, facemasks, oro"haryngeal and naso"haryngeal air4ays, laryngeal masks, and other s,"raglottic de)ices e-g- Combit,be- :t may be carried o,t 4hen int,bation e3,i"ment or skills are ,na)ailable, if int,bation is diffic,lt or on a "atient 4ith a "artially obstr,cted air4ay(rgency is an im"ortant factor in "lanning and sec,ring an air4ay in the most a""ro"riate manner- This 4ill de"end on risk of )ocal cord in/,ry, degree of "atient co+o"eration, anatomy of air4ay, e3,i"ment to hand and yo,r o4n ex"erienceXefore yo, start 0IJ Think abo,t sim"le "ositioning and the reco)ery "osition of the "atient es"ecially for air4ay "rotection alone ;ssess for air4ay obstr,ction o COOK =into mo,th and for chestFabdominal mo)ement?o o o

C: TEN =snoringFg,rglingF4hee@ing? DEEC =ex"ired air?0IJ Com"lete air4ay obstr,ction is silent

Make s,re that yo, ha)e:

o o o o

Oxygen t,bing,ction e3,i"ment;mb,+bag5ebreathe bag-

Hints

; f,lly conscio,s talking "atient is able to maintain hisFher o4n air4ay and needs no f,rther assessment-

6o not ,se head tilt or chin lift in s,s"ected cer)ical s"ine in/,ry exce"t as a last resortP-.O. Xox !'-B Common ca,ses of air4ay obstr,ction Tong,e =d,e to ,nconcio,sness? oft tiss,e s4elling =tra,ma, t,mor?

Doreign material =blood, )omit?6irect in/,ryecretions-

Xronchos"asm-

Xox !'-. ec,re air4ays ; sec,re air4ay may be necessary in "atients 4ith the follo4ing: ;"noea MC ] OF!.

High as"iration risk5es"iratory fail,re(nstable mid+face tra,ma;ir4ay in/,ries-

P-.OG ;ir4ay manoe,)res The follo4ing are "erformed 4ith the "atient lying s,"ine and all aim to o"en the air4ay 4ith sim"le "hysical manoe,)res- These are ,sef,l as a first ste" in managing a "atient 4ith a com"romised air4ay and are ,sed in con/,nction 4ith an oxygen mask- ;lso ,sef,l in sit,ations 4here the are no air4ay de)ices a)ailable:f ,ns,ccessf,l, yo, sho,ld go on to ,se additional e3,i"mentHead tilt Place hands aro,nd "atientHs forehead and tilt back4ards so as to achie)e ,""er cer)ical extension =Dig- !'-!L?Chin lift (s,ally ,sed 4ith the head tilt Place the ti"s of the index and middle fingers of yo,r right hand ,nder the front of the "atients mandible

Cift ,"4ards, ",lling the mandible anteriorly =Dig- !'-!O?-

Ja4 thr,st (se this if there is s,s"icion of an in/,ry to the cer)ical s"ine- ; t4o+handed techni3,e Holding that "atient from behind, "lace the fingers of both hands behind the angle of the mandible

Cift the mandible 4ith these fingers 4hilst ,sing yo,r th,mbs to dis"lace the chin do4n4ards, o"ening the mo,th =Dig- !'-%&?-

Dig- !'-!L Performing a head+tiltP-.O'

Dig- !'-!O Performing a chin+lift-

Dig- !'-%& Performing a /a4+thr,st0IJ Hint 6o not ,se a head+tilt or chin lift in a "atient 4ith =or s,s"ected to ha)e? cer)ical s"ine in/,riesP-.OL ;ir4ay de)ices Dacemasks 0IJ (se the smallest fitting mask to fit o)er mo,th and noseThis is a sim"le mask that is fitted o)er the nose and mo,th- Eo, may ,se an air4ay to aid )entilation or to clear any obstr,ctionOne hand techni3,e Place yo,r th,mb and index finger on the mask in a 018C019 sha"e =see Dig- !'-%!? Mras" the /a4 4ith remaining fingers ",lling the face into the maskT4o hand techni3,e Place yo,r th,mbs either side of the mo,nt (se yo,r index fingers to s,""ort the body of the mask

Eo,r other fingers can be ,sed to lift the /a4 and extend the neck =Dig- !'-%%?-

P-.OO

Dig- !'-%! (se of a face+mask, one+handed techni3,e-

Dig- !'-%% (se of a face+mask, t4o+handed techni3,eP-G&& Oro"haryngeal air4aylM,edel air4ay 0IJ (se 4hen the "atient is semi+conscio,sThis consists of a flange =limits de"th of insertion?, bite "ortion =teeth of "atient rest against this?, and c,r)ed body =follo4s c,r)at,re of tong,e? 4hich has a l,men allo4ing "assage of air and s,ction-

6ifferent si@es are a)ailable and are colo,r coded- The correct si@e is determined by meas,ring the air4ay against the distance bet4een the corner of the mo,th and the angle of the /a4 =Digs!'-%A and !'-%B?Techni3,e C,bricate and insert air4ay ,"side do4n Once it is 4ell into the mo,th rotate !L&#P and ad)ance to f,ll "ositiono

;lternati)ely, hold tong,e do4n and for4ard 4ith a tong,e de"ressor ,ntil air4ay is in "laceCheck for no gagging, snoring or )omiting and that air is mo)ing inFo,t-

(se a si@e !&F!%F!B catheter for s,ction, if re3,ired-

Dig- !'-%A Oro"haryngeal air4aysP-G&!

Dig- !'-%B Chose the si@e of the oro"haryngeal air4ay by meas,ring from the "atientHs teeth to the angle of the mandibleP-G&% Naso"haryngeal air4ay 0IJ Tolerated better than the oro"haryngeal air4ay in alert "atientsThis consists of a flange =limits de"th of insertion?- The "haryngeal end has a be)el to facilitate a non+tra,matic insertion and c,r)ed body 4ith l,men allo4ing "assage of air and s,ction- ome air4ays come 4itho,t an ade3,ate flange, so a safety "in is ,sed at the nasal end to "re)ent the air4ay falling back into the noseY =see fig,re?6ifferent si@es are a)ailable- 6etermine the correct si@e by com"aring 4ith the distance bet4een the nostril and the trag,s =see Dig- !'-%.?Techni3,e The 4ider nostril is traditionally chosen b,t most air4ays are be)elled for introd,ction into the left nostril C,bricate air4ay and "ass directly into nasal "assage "assing along the floor of the nose or aiming for the back of the o""osite eyeball

(se a si@e !&F!% catheter for s,ction, if re3,ired-

P-G&A

Dig- !'-%. Naso"haryngeal air4ays-

Dig- !'-%G Chose the si@e of the naso"haryngeal air4ay by meas,ring from the "atientHs nostril to the trag,sP-G&B Caryngeal mask air4ay =CM;?

This consists of a t,be 4ith an inflatable c,ff 4hich is designed to seal aro,nd the laryngeal o"ening- :t re3,ires the "atient to be dee"ly ,nconscio,sTechni3,e Maintain oxygenation by bag and mask 6eflate the c,ff of the CM; ,sing a %&ml syringe

C,bricate the o,ter c,ff 4ith a3,eo,s gel- This "art 4ill not be in contact 4ith the larynxThe "atient sho,ld be in a s,"ine "osition 4ith the head and neck in alignmenttand behind the "atient or if this is not "ossible, from the frontHold the t,be like a "en and "ass into the mo,th 4ith the distal a"ert,re facing the feet of the "atientP,sh back o)er the tong,e 4hile a""lying the ti" to the s,rface of the "alate ,ntil it reaches the "osterior "haryngeal 4allThe mask is then "ressed back4ards and do4n4ards ,ntil it reaches the back of the hy"o"harynx and resistance is feltThe black line on the t,be sho,ld be aligned 4ith the nasal se"t,m:nflate the c,ff 4ith ,s,ally %&+A&ml of airThe t,be sho,ld lift o,t of the mo,th slightly and the larynx is ",shed for4ard if it is in the correct "osition;ttach a breathing circ,it and gently )entilate the "atient 4ith !&&> oxygenConfirm correct "lacement by a,sc,ltating the chest in the axillary regions and obser)e for bilateral chest mo)ement:nsert a bite block or oro"haryngeal air4ay alongside the t,be and sec,re the air4ay 4ith the bandage or tie "ro)ided-

P-G&.

Dig- !'-%' ; laryngeal mask air4ay<e thank Heidi 5idsdale for her assistance 4ith this to"icP-G&G

Tracheostomy management Theory ; tracheostomy is an o"ening in the anterior 4all of the trachea belo4 the larynx 4hich can facilitate )entilationFres"iration; mini+tracheostomy is a narro4 diameter c,ffless t,be that is inserted into the trachea thro,gh 4hich a catheter can be "assed to stim,late a co,gh andFor s,ction- :s not a method for "rotecting the air4ay or deli)ering any kind of )entilatory s,""ort exce"t emergency oxygen thera"yTracheostomy may be "erformed if the need for an endotracheal t,be is "rolonged, to facilitate 4eaning, identification of an inability to maintainF"rotect air4ay, and to sec,re and clear an air4ayPatients may ha)e a "ermanent tracheostomy in "lace or e)en a stoma- These often do not need h,midification or s,ction ,nless the "atient is ac,tely ,n4ellE3,i"ment ex"lained The tracheostomy t,be The tracheostomy t,be may be stitched in or sec,red aro,nd the neck and is either single or do,ble l,men =has an inner t,be that can be remo)ed for cleaning?- The t,bes are either fenestrated or non+fenestratedDenestrated t,bes allo4 the "assage of air and secretions into the mo,th- These are good for 4eaningH,midification

Heated h,midification is ,sed for the short term and is the 018gold standard019 ; heat moist,re exchanger = 4edish nose, thermo)ent? is ,sed for "atients 4ith minimal secretions or 4ho are mobileProced,res O"en s,ction ;im is to remo)e secretions and "re)ent blockages in the tracheotomy t,be, bronchial obstr,ction and al)eolar colla"se (se a catheter 4ith diameter no more than one !F% internal tracheotomy diameter- `= i@e of o,ter diameter? +%Z[%01U e-g- L-&mm + % Z[ % a !%b Negati)e "ress,re sho,ld be !&&+!.&mmHg =!A-.+%&kPa?

<ear glo)es, a"ron, and "rotecti)e eye 4ear;ttach a sterile catheter to s,ction e3,i"ment ens,ring a good seal and lea)e most of the "ackaging in "lacePlace ,nder non+dominant armP,t a clean dis"osable glo)e on the dominant hand and do not to,ch anything other than the catheter ti"P,ll the "ackaging a4ay 4ith non+dominant handO"en the s,ction "ort:ntrod,ce the ti" of the catheter into the tracheotomy t,be 4ith the dominant hand gently b,t 3,ickly6e"th of insertion sho,ld be &-.+!-&cm beyond end of the tracheostomy t,be =abo,t !FA length of catheter?:nsert ,ntil "atient co,ghsP-G&'

<ithdra4 ti" &-.cm and a""ly s,ctionContin,e to 4ithdra4 slo4ly and contin,o,slyClose s,ction "ort and discard glo)e and catheter into bin 0IJ ,ction sho,ld last no more than !. seconds 0IJ ;llo4 s,fficient time bet4een "asses for reco)ery5e"eat ,ntil secretions are cleared-

;fter s,ction, ens,re "atient is reconnected to res"iratory s,""ort and oxygen and that oxygen le)els are ret,rned to normal-

T,be occl,sion Call for hel" 5eass,re the "atient

;sk the "atient to co,gh or attem"t to clear secretions )ia s,ction5emo)e inner cann,la and re"lace 4ith ne4 one:f no inner cann,la, deflate c,ff and administer oxygen facially, instill %+.ml of &-O> saline and s,ction to try to clear blockage:f ,nable to clear blockage, a total t,be change may be re3,ired =try ,sing smaller si@e if necessary?:f t,be insertion fails then consider mask to stoma )entilation =consider s,ction )ia stoma?0IJ :f res"iration sto"s all together, ",t o,t a 018crash call019, call for anaesthetist, inflate the c,ff and man,ally )entilate ,sing catheter mo,nt and rebreathe or amb,+bag-

4allo4ing assessment This sho,ld be "erformed by a com"etent "ractitioner =e-g- s"eech and lang,age thera"ist? it the "atient ," ,ction )ia tracheotomy "rior to c,ff deflation

6eflate c,ff f,lly if "ossible or the maximal the "atient can tolerate or as agreed by the M6TEns,re there is an a""ro"riate inner cann,la in "laceMi)e the "atient si"s of 4ater from a teas"oon and follo4 the "roced,re ex"lained on "-A!G-

:ntermittently check for )oice 3,ality =ask the "atient to say 018ah019 or co,nt o,t lo,d?to" if "atient deteriorates, fatig,es, sho4s signs of "ersistent co,ghing, as"iration on s,ction, or "ersistently 0184et019 )oicePractise techni3,es before needing them in an emergencytridor is a good indication that an air4ay is "artially blocked;l4ays remember to h,midify oxygen in tracheostomy "atients-

Hints

<e thank Heidi 5idsdale for her assistance 4ith this to"ic-

P-G&L

Endotracheal =ET? int,bation Theory There are A main indications for tracheal int,bation: relie)ing air4ay obstr,ction, "rotecting the air4ay from as"iration, and facilitating artificial )entilation of the l,ngs0IJ 5emember, if yo, are inex"erienced in this techni3,e, ne)er "erform tracheal int,bation ,ns,"er)i@ed0IJ :n an emergency sit,ation, it is safer to "roceed to bag and mask the "atient or ,se a laryngeal mask air4ay if one is a)ailable and a4ait senior assistanceE3,i"ment Caryngosco"e =check b,lb?012,s,ally si@e A is ade3,ate election of ET t,bes =si@e ' in most 4omen and si@e L in most men?

terile l,bricant%&ml syringe for c,ff inflationTa"e to tie t,be in "laceM,m012elastic bo,gie, or rigid stiletteelf+inflating bag and oxygen s,""lytethosco"e for confirming correct "osition of t,be,ction a""arat,s 4ith a 4ide bore rigid s,ction end =Eanka,er?-

Proced,re :n the a4ake "atient, introd,ce yo,rself, confirm the "atientHs identity, ex"lain the "roced,re, and obtain )erbal consent <ash yo,r hands and ",t on a "air of glo)es

Pre+oxygenate the "atient 4ith a high concentration of oxygen for a minim,m of !. seconds0IJ 5emember, int,bation m,st take no longer than A& secondsPosition the neck s,ch that it is distally extended and "roximally slightly flexed "osition 4ith a small "illo4 ,nderneath the head012an exaggeration of the normal cer)ical lordosiso

0IJ :f a cer)ical in/,ry is s,s"ected, the head and neck sho,ld be maintained in ne,tral alignment-

tand at the head of the bed and o"en the mo,th:ns"ect for loose dent,res or foreign material012remo)e any if "resent-

Hold the laryngosco"e in the left hand and look do4n its length as yo, insertlide the sco"e into the right side of the mo,th ,ntil the tonsillar fossa comes into )ie4No4 mo)e the blade to the left so that the tong,e is ",shed into a midline "osition;d)ance, follo4ing the "osterior edge of the soft "alate ,ntil the ,),la comes into )ie4;d)ance the blade o)er the base of the tong,e and the e"iglottis sho,ld "o" into sightP-G&O

<ith the blade "ositioned bet4een the e"iglottis and base of the tong,e =)allec,la?, a""ly traction in the line of the handle of the laryngosco"eo This mo)ement sho,ld lift the e"iglottis and ex"ose the )+sha"ed glottis behindOnce the triang,lar+sha"ed laryngeal inlet is in )ie4, "osition the ET bet4een the )ocal cords so that the t,be is /,st distal to themo o

(se the mark on the t,be abo)e the c,ff to indicate the correct "ositionThis is aro,nd %!cm in a female and %%cm in a male-

:f diffic,lty is ex"erienced "assing the ET t,be into the larynx, "ass a g,m elastic bo,gie first and then try "assing a l,bricated ET t,be o)er thisOnce the ET t,be is in "osition, inflate the c,ff 4hile )entilating thro,gh the ET 4ith a self+inflating bag7erify correct "ositioning of the t,be by obser)ing chest mo)ement and a,sc,ltate at the sides of the chest in the mid+axillary line =both sides of the chest sho,ld mo)e e3,ally and yo, sho,ld hear breath so,nds at both l,ng bases?ec,re the ET t,be 4ith a tieObtain a C\5 to confirm the t,be "osition- The ET has a radio+o"a3,e line 4ithin it6oc,ment the details of the "roced,re in the notes-

:m"ortant note 0IJ The insertion of the ET t,be sho,ld take no more than A& seconds from start to finish- :f A& seconds "ass and the t,be is not in the correct "osition, remo)e all the e3,i"ment and bagFmask )entilate the "atient ,ntil yo, are ready to try againome com"lications of ET int,bation Tra,ma+to teeth, air4ay, larynx, or trachea ;s"iration-

;ir4ay obstr,ctionT,be mis"lacementHy"oxia from "rolonged attem"tsTracheal stenosis =late com"lication?-

P-G!&

Dig- !'-%L ET t,be 4ith attached syringe- Note the c,ff has been inflated to demonstrateP-G!! P-G!%

Non+in)asi)e )entilation =N:7? Theory N:7 is the a""lication of "ositi)e "ress,re )entilatory s,""ort )ia a facial or nasal interface and not )ia an air4ay =ETT, tracheostomy?- N:7 sho,ld be o"erated only by trained staff in an a""ro"riate area- :t may be ,sed in ac,te conditions in hos"ital or in chronic conditions at homePatients need to be s"ontaneo,sly breathing, maintaining their air4ay =i-e- conscio,s?, and com"liant- :t is not a s,bstit,te for mechanical )entilation ,nless this has been decided as the 018ceiling019 of treatmentPress,res are ,s,ally doc,mented in cmH%O =rather than mmHg or kPa? and it is good "ractice that a decision of maximal "ress,re to be ,sed is doc,mented in the medical notes so that if a "atient contin,es to deteriorate, the M6T has an a""ro"riate management strategy in "laceContraindications (ndrained "ne,mothorax and ",lmonary haemorrhage- :t is good "ractice to re)ie4 a recent C\5 to r,le these o,t before beginningCa,tions

X,llae, ,nstable cardio)asc,alar system, abscess, facial tra,ma, basal sk,ll fract,re, recent bronchial or oeso"hageal s,rgery, "ersistent )omiting, high bronchial t,mo,rCP;P Contin,o,s Positi)e ;ir4ays Press,re =CP;P? ,ses a single "ress,re contin,o,sly thro,gho,t both ins"iratory and ex"iratory "hases:t is ,sed in the treatment of ty"e : res"iratory fail,re =obstr,cti)e slee" a"noea, cardio+ ",lmonary oedema and occasionally in ",lmonary embol,s, "ne,monia and 4eaning from )entilation?XiP;P Xile)el Positi)e ;ir4ays Press,re =XiP;P? )entilation ,ses different "ress,res on ex"iration =EP;P? and on ins"iration =:P;P?- Higher EP;P increases D5C 4hilst higher :P;P a,gments tidal )ol,me- The system is normally "ress,re dri)en b,t can be )ol,me dri)en(sed in the treatment of ty"e :: res"iratory fail,re =i-e- hy"o)entilation, chronic ne,rom,sc,lar conditions, exacerbations of COP6?P-G!A Xox !'-G etting ," N:7 This is not something that the st,dent or early /,nior doctor 4ill be ex"ected to do- The follo4ing is a brief g,ide that sho,ld allo4 yo, to ,nderstand 4hat is in)ol)edCP;P E3,i"ment Mask, head stra", PEEP )al)es =.+'-.+!&cm H%O? Circ,it, safety 018blo4+off019 )al)e

High flo4 generator for oxygen and airHeated h,midification-

Proced,re Ex"lain all of the follo4ing to the "atient and obtain )erbal consent (se meas,ring tem"lates to assess a""ro"riate si@e interface and minimi@e air leaks

et oxygen and flo4 rate and ens,re the PEEP )al)e o"ens a small distance only and ne)er f,lly closestart 4ith a lo4 "ress,re and slo4ly increase for "atient comfort and to gain com"liance;im to red,ce the 4ork of breathingContin,o,sly monitor ;XMF aO%, heart rate, and XP- <atch for abdominal distension-

XiP;P E3,i"ment Mask =facialFnasal?, "rongs, f,ll face mask, head stra" Circ,it, exhalation "ort

Entrained oxygen if re3,ired-

Heated h,midification7entilator =N:PP7!F%FA, Xreas, XiP;P )ision?-

Proced,re Ex"lain all of the follo4ing to the "atient and obtain )erbal consent (se meas,ring tem"lates to assess a""ro"riate si@e interface and minimi@e air leaks

tart 4ith lo4 "ress,res and slo4ly increase for "atient comfort and to gain com"liance=Trial data in COP6 is based on "ress,res of %&F.-? etting ins"iratory and ex"iratory times 4ill need to be contin,o,sly reassessed as res"iratory rate 4ill change o)er time:nitially aim to match the "atients o4n )entilatory "attern b,t e)ent,ally aim to 0Q^ res"iratory rate and 0QR tidal )ol,meFflo4 ,sing the minimal "ress,res "ossibleMonitor ;XMF aO%, heart rate and XP at ! and B ho,rs- <atch for abdominal distension-

<e thank Heidi 5idsdale and Dranco M,arasci for their assistance 4ith this to"icP-G!B

Ple,ral fl,id sam"ling Theory ;fter identifying a "le,ral eff,sion, a small )ol,me of fl,id may be as"irated and sent for biochemical, cytological, and microbiological analysis; ne,ro)asc,lar b,ndle r,ns on the inferiorFinner as"ect of each rib, to a)oid this, needles for as"iration are inserted immediately abo)e a ribE3,i"ment Trolley terileF4o,nd care "ack

terile glo)es;ntise"tic sol,tion.ml syringe%&ml syringe! )ial of local anaesthetic =,s,ally !> lidocaine?election of needles =% green, ! orangeFbl,e?% sterile sam"le containers! "air of c,lt,re bottles-

Xiochemistry t,be for gl,cose sam"le-

Proced,re :ntrod,ce yo,rself, check the "atientHs identity, ex"lain the "roced,re, obtain )erbal consent, and ,n4ra" the e3,i"ment Position the "atient comfortably sitting ,"right on the edge of the bed, leaning for4ard 4ith arms raised012,se a "illo4 on a raised bedside trolley for the "atient to lean on =see Dig- !'-%O?

Perc,ss the ,""er border of the eff,sion "osteriorly and choose a site ! or % intercostal s"aces belo4 thatMark the chosen s"ot at the ,""er edge of a rib 4ith a "en<ash hands and ",t on the sterile glo)esClean the marked area ,sing the antise"tic sol,tion on a cotton ball- <ork o,t4ards in a s"iralling fashion6ra4 ," .ml of the lidocaine ,sing the green needle4a" the needle for an orange one and infiltrate the skin creating a s,rface bleb4a" for a green needle and infiltrate anaesthetic dee"er- ;d)ance the needle in a ste"+ 4ise manner+dra4ing back the syringe each time it is ad)anced to ens,re )asc,lat,re is a)oided and infiltrating anaesthetic before ad)ancing againOnce yo, reach the "le,ral ca)ity, a flash+back of "le,ral fl,id may be obtainedTake the %&ml syringe, attach a green needle and as"irate %&ml of "le,ral fl,id, being caref,l to ,se the anaestheti@ed tract<ithdra4 the needle and co)er the 4o,nd 4ith a s,itable dressing =dry ga,@e and medical sticky ta"e 4ill s,ffice?P,t Bml of fl,id in each bottle and send to the laboratories for:
o o o

Xiochemistry ="H, "rotein, C6H, amylase, gl,cose?CytologyMicrobiology =MC and "l,s TX stain and c,lt,re if indicated?-

5e3,est a C\5 "ost+"roced,re to check for "ne,mothorax only if the "roced,re 4as diffic,lt or high+risk-

P-G!.

Dig- !'-%O Position a "atient comfortably leaning for4ard012,se a bedside trolley and "illo4 for them to lean on 4ith their arms crossed-

Dig- !'-A& :nsert the needle /,st abo)e a rib, at the lo4er border of the intercostal s"ace to a)oid the ne,ro)asc,lar b,ndleHints 0IJ :f the lab is to meas,re "H, the sam"le m,st be sent to the laboratory immediately-

ome laboratories 4ill not meas,re "H012check before yo, begin- ;n alternati)e is to sa)e a small amo,nt of fl,id, dra4 it ," in a "rimed blood gas syringe and r,n it thro,gh a blood gas analyser to gain an instant "H meas,rement:n larger indi)id,als, the "le,ral ca)ity may be at some de"th from the skin- :f this is the case, ,se a longer needle012needles of :7 cann,lae are often significantly longer des"ite being the same ga,ge-

P-G!G

Chest drain insertion Theory 6rains are inserted to drain either fl,id ="le,ral eff,sionFem"yema? or air ="ne,mothorax? from the "le,ral ca)ity- :n both cases, the insertion of the drain is almost entirely identicalThe drain is connected to a b,cket 4ith a small amo,nt of 4ater =creating an air+tight seal? so that there is no direct connection bet4een the "le,ral ca)ity and the air- On ins"iration, the negati)e intrathoracic "ress,re dra4s 4ater ," the t,be =abo,t Bcm?; on ex"iration, the 4ater le)el falls and =if draining a "ne,mothorax? air b,bbles thro,gh the 4ater- This one+4ay )al)e allo4s air or fl,id to drain from the chest b,t not re+enterThe method described belo4 is the 018 eldinger techni3,e019- Other techni3,es exist for 4ide+ bore drains b,t these are no4 only ,sed in the setting of bl,nt tra,ma and cardiothoracic s,rgery012or for other "roblems s,ch as extensi)e s,rgical em"hysema o)erlying a "ne,mothoraxE3,i"ment Trolley !&ml !> lidocaine

!&ml syringe! orange needle! green needleterile glo)esterile "ack =containing cotton balls, container and dra"e?:ncontinence "ad,itable dressing =e-g- Hy"ofix#S or drainfix#S?eldinger chest drain kit =containing chest drain, introd,cer, chest drain needle, syringe, scal"el, A+4ay ta", g,ide 4ire?,t,re =no- !.?-

:odine sol,tionChest drain t,bingChest drainage bottle.&&ml sterile 4ater-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent 6o,ble+check the history and C\5 to be s,re of 4hich side needs the drain

Position the "atient sitting on a chair or the edge of their bed, arms raised- :nstead of asking the "atient to hold their arm o)er their head, it is often easier to ask them to cross their arms and lean on a bedside table 4ith a "illo4, raised le)el 4ith their sho,lders, =see Dig- !'-%O?Tri"le+check the side by briefly examining the "atient =ta" o,t the d,llness of an eff,sion or listen for the 0Q^ breath so,nds of a "ne,mo?The ,s,al site for insertion is in the mid+axillary line, 4ithin a triangle formed by the dia"hragm, the latissim,s dorsi and the "ectoralis ma/or- =Dig- !'-A!?- Dor a"ical "ne,mothoraces, yo, may 4ish to choose the %nd intercostal s"ace in the mid+cla)ic,lar linePlace the incontinence "ad on the bed to mo" ," any s"illagesMark yo,r chosen s"ot =/,st abo)e a rib to a)oid hitting the ne,ro)asc,lar b,ndle? 4ith a "enterili@e the area 4ith antise"tic sol,tion or iodine on cotton balls 4orking in a s"iral "attern o,t4ards from the insertion "ointP-G!'

(sing the syringe and the orange needle, anaestheti@e the skin =see "-..%? forming a s,bc,taneo,s bleb4a" the orange needle for the green one and anaestheti@e dee"er, remembering to as"irate before in/ecting to ens,re that yo, ha)e not hit a )essel- ;naestheti@e right do4n to the "le,ral ca)ity and only sto" 4hen yo, as"irate air or "le,ral fl,id(se the scal"el to make a small c,t in the skin-

No4 ,se the drain+kit needle 4ith the c,r)ed ti" and syringe =in some kits, this has a central stilette 4hich needs to be remo)ed first?- <ith the c,r)ed ti" facing do4n4ards =,"4ard for a "ne,mothorax?, ad)ance thro,gh the anaestheti@ed ro,te ,ntil yo, are as"irating either air or fl,id again5emo)e the syringe and hold the needle steadyThread the g,ide+4ire thro,gh the needle into the "le,ral ca)ity =this ,s,ally comes "re+ coiled b,t often needs to be retracted slightly first to straighten the c,r)e on the ti"?- ee Dig- !'-A%Once the 4ire is half in the chest, discard the co)eringNo4 4ithdra4 the needle from the chest b,t be s,re to not remo)e the g,ide 4ire012KEEP HOC6 OD :T ;T ;CC T:ME Thread the needle right off the end of the g,ide 4ire- Eo, sho,ld no4 ha)e the 4ire in the chest b,t nothing elseThread the introd,cer o)er the g,ide 4ire and into the chest, t4isting back and forth as yo, go to o"en ," a tract for the drainHs "assage- Eo, can then slide the introd,cer back off the 4ire012b,t be caref,l not to ",ll the 4ire o,t of the chestThe chest drain has a central stiffener in "lace, lea)e this in sit,- No4 thread the drain o)er the 4ire and into the chest, c,r)ing do4n4ards- ;l4ays HOC6 ON TO THE <:5E 4ith one hand012yo, may need to ",ll the 4ire o,t of the chest slightly so that it "rotr,des from the end of the drain before yo, ",sh the drain into the chest- Eo, donHt 4ant to ",sh it right into the chest and lose itY Once the drain is in "lace, yo, can 4ithdra4 the 4ire and the central stiffenerc,ickly attach the A+4ay ta" and make s,re all the "orts are closed5elaxEo, can no4 stitch the drain in "lace- This neednHt be com"licated012a sim"le stitch /,st abo)e the drain 4ill s,ffice 4ith the ends then 4ra""ed tightly aro,nd the drain knotted se)eral timesDix the drain in "lace 4ith a 018drainfix#S019 or another s,itable dressing;ttach the drain to the t,bing and the t,bing to the drain collection bottle 4hich yo, ha)e "re+filled 4ith .&&ml of sterile 4aterO"en the A+4ay ta"- Eo, sho,ld either see the fl,id start to flo4 or air start to b,bble in the collection bottle- ;sk the "atient to take a fe4 dee" breaths and 4atch the 4ater le)el in the t,bing to ens,re it is rising and falling =018s4inging019?<arn the "atient not to knock the bottle o)er and kee" it belo4 the le)el of their ,mbilic,s-

5e3,est a "ost+insertion C\5-

P-G!L

Dig- !'-A! Correct "ositioning of the "atient for chest drain insertion and ideal site of drain insertion-

Dig- !'-A% Pre"are the g,ide+4ire before starting the "roced,re by retracting slightly so as to straighten the c,r)ed ti"-

P-G!O

Dig- !'-AA 6iagrammatic re"resentation of a s,itable stitch to hold the drain in "laceP-G%&

Nasogastric =NM? t,be insertion Theory ; "lastic t,be is inserted thro,gh the nose, do4n the back of the throat, oeso"hag,s and into the stomachThe 018bore019 of the t,be =large a !G, medi,m a !%, small a !&? is dictated by the t,bes intended ",r"ose- Dor short+ or medi,m+term n,tritional s,""ort in those 4ith a defecti)e s4allo4, a fine+bore t,be is ,sed- Carger bores are ,sed to drain the stomach contents and decom"ress intestinal obstr,ctionContraindications: se)ere facial tra,ma and basal sk,ll fract,resCom"lications: as"iration, tiss,e tra,ma, electrolyte loss, tracheal or d,odenal int,bation, "erforation of oeso"hag,s or stomachE3,i"ment 6is"osable glo)es Plastic a"ron

6ra"eC,bricant gelNM t,beC," of 4ater #_ stra4.&ml syringe6rainage bag =if necessary?-

;dhesi)e ta"e or steristri"s and hy"ofix6is"osable )omit bo4lPa"er to4el-

Proced,re :ntrod,ce yo,rself, confirm the "atientHs identity, ex"lain the "roced,re, and obtain )erbal consent <ash hands thoro,ghly, ",t on glo)es and "lastic a"ron

:deally, the "atient sho,ld be seated ,"right =often the head tilted slightly for4ards can aid insertion?Examine "atientHs nose for deformityFobstr,ctions and decide 4hich nostril to ,se(se the t,be to meas,re the distance xi"histern,m 0Qd earlobe 0Qd ti" of nose and note the distanceC,bricate the first B+Lcm of t,be- Eo, may also 4ish to ,se local anaesthetic s"ray on "atientHs throat if a)ailablePass the t,be into the nostril, and then "osteriorly, a short distance at a time- Eo, 4ill feel it t,rn the corner at the naso"harynx and another slight obstr,ction as it "asses into the oeso"hag,s:f the "atient is able, they sho,ld be asked to s4allo4 as the t,be "asses the "harynx012a brief si" of 4ater may hel" here;d)ance the t,be as far as the "re+meas,red distanceTo check for correct "lacement, yo, may 4ish to as"irate some stomach contents 4ith the syringe and test the fl,idHs "H =sho,ld be ]G?ec,re the t,be to the "atientHs nose 4ith some ta"e, yo, may also 4ish to c,rl it back o)er their ear and sec,re it to their cheek5e3,est a C\5 and confirm the t,beHs "osition =belo4 dia"hragm in the region of the gastric b,bble? before ,sing for feedingOnce the "osition is confirmed, remo)e the central g,ide4ire before ,se and sa)e this =,se a "lastic "age+file and file in the n,rsing notes?Ens,re that yo, record the "roced,re in the "atientHs notes-

P-G%! 0IJ Hints :f resistance if felt, try rotating the t,be 4hilst ad)ancing- Ne)er force-

Partially "re+free@ing the t,be can ease its "assage;n alternate test of correct "lacement: insert a small 3,antity of air =%&+A&ml? do4n the t,be ,sing the syringe 4hilst listening to the e"igastri,m 4ith the stethosco"e- Eo, sho,ld hear the air entering the stomach- =NX This techni3,e is no longer considered a""ro"riate in the (K and health care 4orkers are ad)ised against ,sing it?-

<e thank Cyn 6ean for her hel" 4ith the "re"aration of this "age P-G%%

;scitic ta" Theory ; needle is inserted thro,gh the abdominal 4all allo4ing the 4ithdra4al of a small amo,nt of fl,id for diagnostic ",r"osesE3,i"ment ! green needle ! orange needle

!&ml syringe%&ml syringe.+!&ml !> lidocaine sol,tion:odine or antise"tic sol,tionMicrobiology c,lt,re bottles =anaerobic and aerobic?terile "ack =incl,ding glo)es, cotton balls and container?% sterile collection bottlesXiochemistry t,be =gl,cose?Haematology t,b-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Ens,re that the "atient has em"tied their bladder

Position the "atient lying s,"ine or in the lateral dec,bit,s "osition lea)ing the right side a)ailable012,ndress ex"osing the abdomenPerc,ss the extent of the ascitic d,llness = "-%G&?-

Mark yo,r chosen s"ot in the region of the right iliac fossa ="referably? 4ithin the area of d,llnessClean the area thoro,ghly 4ith antise"tic and don the sterile glo)es:nfiltrate the skin and s,bc,taneo,s tiss,es 4ith lidocaine )ia the orange needle and !&ml syringe and 4ait a min,te for it to take effect;ttach the green needle to the %&ml syringe and insert into the abdomen, "er"endic,lar to the skin- ;d)ance the needle as yo, as"irate ,ntil fl,id is 4ithdra4n;s"irate as m,ch fl,id as "ossible =," to the %&ml?5emo)e the needle and a""ly a s,itable sterile dressingP,t WBml of fl,id in each bottle and send to the laboratories for:
o o o o o

Xiochemistry012standard collection bottle =alb,min, C6H, amylase?Xiochemistry012acc,rate gl,cose collection t,be =gl,cose?CytologyHaematology =total and differential 4hite cell co,nt?Microbiology =MCe ?-

P-G%A

Dig- !'-AB Performing a diagnostic ascitic ta"P-G%B

;bdominal "aracentesis =drainage? Theory ; drain is inserted into the abdominal ca)ity allo4ing drainage of large amo,nts of ascitic fl,id for thera"e,tic ",r"oses-

The "roced,re belo4 relates to a Xonanno drainage kit012the essence is the same for other catheter kits altho,gh minor details may differ- Eo, sho,ld refer to the man,fact,rerHs instr,ctionsE3,i"ment ! orange needle ! green needle

% Z[!&ml syringes.+!&ml !> lidocaine sol,tion:odine or antise"tic sol,tionterile "ack =incl,ding glo)es, cotton balls and container?Xonanno abdominal catheter "ack =catheter, slee)e, ",nct,re needle and ada"tor clam"?Catheter bagCatheter bag standcal"el-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Ens,re that the "atient has em"tied their bladder

Position the "atient lying s,"ine or in the lateral dec,bit,s "osition lea)ing the right side a)ailable012,ndress ex"osing the abdomenPerc,ss the extent of the ascitic d,llness = "-%G&?-

Mark yo,r chosen s"ot in the region of the right iliac fossa ="referably? 4ithin the area of d,llnessClean the area thoro,ghly 4ith antise"tic and don the sterile glo)es:nfiltrate the skin and s,bc,taneo,s tiss,es 4ith lidocaine )ia the orange needle and !&ml syringe and 4ait a min,te for it to take effect;ttach the green needle to the other !&ml syringe and insert into the abdomen, "er"endic,lar to the skin- ;d)ance the needle as yo, as"irate ,ntil fl,id is 4ithdra4nPre"are the catheter kit012straighten the catheter =4hich is c,rled in the "ack? ,sing the "lastic co)ering sheath "ro)ided-

Take the needle "ro)ided in the "ack and "ass thro,gh the sheath s,ch that the needle be)el is directed along inside the c,r)e of the catheter012contin,e ,ntil the needle "rotr,des from the catheter ti"Close off the r,bber b,ng at the end of the catheterMake a small incision in the skin ,sing the scal"elMras" the catheter needle WBH abo)e the distal end and, 4ith a firm thr,st, ",sh the needle thro,gh the abdominal 4all to WAcm dee"6isengage needle from the catheter h,b and ad)ance catheter ,ntil the s,t,re disc is flat against the skin<ithdra4 needleConnect ada"tor+clam" to the catheter h,b and sec,rely attach the r,bber "ortion of the clam" into a standard drainage catheter bagCaref,lly s,t,re the catheter into the abdominal 4all012yo, may also need to a""ly f,rther ta"e to ens,re the catheter 4onHt fall o,tEns,re the clam" is o"en to allo4 fl,id to drain=Y?

P-G%.

Dig- !'-A. The assembled catheter com"onents-

Dig- !'-AG :nserting the needle into the c,r)ed catheterHints :n cirrhotic "atients, "rotein loss sho,ld be re"laced =and haemodynamic stability maintained? by inf,sing h,man alb,min sol,tion =H; ? :7 at a rate of !&&ml of %&> H; for e)ery %-.C of ascitic fl,id drained012check local "rotocols 4ith the gastroenterology de"t (s,ally catheters are not left in "lace for *%B ho,rs

6,ring drainage, the flo4 may sto" s,ggesting that the drain is blocked012this may be "ositional and sim"ly mo)ing the "atient may sol)e the "roblem-

P-G%G

Male ,rethral catheteri@ation Theory ; ,rinary catheter has a balloon near the ti" 4hich is inflated )ia a sidearm near the other endOnce inside the bladder, the inflated balloon "re)ents it falling012or being ",lled012o,tE3,i"ment ; catheter "ack =containing a kidney dish, a small "ot 4ith cotton balls, a sterile to4el, sterile ga,@e, sterile glo)es? ;ntise"tic sol,tion or sachet of saline

!&ml !> lignocaineFl,bricant gel in "re+filled syringe =eg :nstilligel#S?!&ml 4ater+filled syringe; catheter bag =leg bag if sit,ation is not ac,te?; male catheter =!%D or !BD?-

Proced,re <ash hands thoro,ghly- Confirm the "atientHs identity, ex"lain "roced,re, and obtain )erbal consent-

(n4ra" all the e3,i"ment onto a trolley in an ase"tic fashion and "o,r saline sol,tion o)er the cotton ballsPosition the "atient s,"ine 4ith genitalia ex"osed- 5aise bed to a comfortable height<ash hands again and ",t glo)es on- Create a hole in the centre of the to4el and dra"e o)er the "atient so the "enis can be reached thro,gh the holeDrom here on, ,se yo,r non+dominant hand to hold the "enis 4ith some ga,@eClean the "enis 4ith the 4et cotton balls, 4orking a4ay from the meat,s- 5emember to retract the foreskin and clean beneathCift "enis to a )ertical "osition, caref,lly "osition the no@@le of the l,bricant gel inside the meat,s and instill the f,ll !&ml slo4ly- =:f "ro)ing "roblematic, can be aided by gentle 018milking019 action-? Position the kidney bo4l bet4een the "atientHs thighs to catch s"illages laterThe catheter 4ill be in a "lastic 4ra""er 4ith a tear+a4ay "ortion near the ti"- 5emo)e this "ortion, being caref,l not to to,ch the catheter:nsert the ti" of the catheter into the ,rethral meat,s and ad)ance slo4ly b,t firmly by feeding it o,t of the remaining 4ra""erOn "assing thro,gh the "rostate, some resistance may be felt 4hich, if excessi)e, may be co,ntered by ad/,sting the angle of the "enis by ",lling it to a hori@ontal "osition bet4een the "atientHs legsOn entering the bladder, ,rine sho,ld start to drain- ;d)ance the catheter to the hilt to ens,re the balloon is beyond the ,rethra:nflate the balloon 4ith the !&ml of saline )ia the catheter side+arm"atient to alert yo, to any "ain and 4atch his face5emo)e the syringe and 4ithdra4 catheter ,ntil resistance is felt;ttach draining t,be and catheter bag5e"lace the foreskin, clean and redress the "atient as necessary<arn the

P-G%' Hints

Eo, may 4ish to )erify the "resence of a f,ll bladder 4ith a bladder+scanner before startingCack of ,rine drainage may be ca,sed by: blockage of gel, em"ty bladder or catheter mis"lacement-

;ttem"t to as"irate ,rine ,sing a catheter+ti""ed syringe- Deel for a f,ll bladder- :f there is any do,bt abo,t the "osition of the catheter, remo)e immediately =deflating balloon first? and seek senior ad)ice;l4ays record the resid,al )ol,me012this is essential in cases of ,rinary retentionConsider the ,se of "ro"hylactic antibiotics before the "roced,reCom"lications: "ain, infection, mis"lacement and tra,maPatients 4ith "rostate disease can often ex"erience some mild haemat,ria follo4ing catheterisation- 6onHt 4orry b,t 4atch caref,lly and be s,re the bleeding doesnHt contin,e or form into clots0IJ Xe4are latex allergyY

<e thank Cyn 6ean for her hel" 4ith the "re"aration of this "ageP-G%L

Demale ,rethral catheteri@ation Theory ; ,rinary catheter has a balloon near the ti" 4hich is inflated )ia a side+arm near the other endOnce inside the bladder, the inflated balloon "re)ents it falling012or being ",lled012o,tXear in mind that n,rses tend to catheteri@e females if they are able012so if a doctor is asked to do it, ex"ect the catheteri@ation to be rather trickyY ;l4ays consider antibiotic "ro"hylaxisE3,i"ment ; catheter "ack =containing a kidney dish, a small "ot 4ith cotton balls, a sterile to4el, sterile ga,@e? terile glo)es

aline sol,tion.ml !> lidocaineFl,bricant gel in "re+filled syringe =e-g- :nstilligel#S?!&ml saline+filled syringe; catheter bag; female catheter =!%D or !BD?-

Proced,re <ash hands thoro,ghly- Confirm the "atientHs identity, ex"lain "roced,re, and obtain )erbal consent (n4ra" all the e3,i"ment onto a cleaned =antise"tic? trolley in an ase"tic fashion and "o,r saline o)er the cotton balls-

Position the "atient s,"ine 4ith knees flexed and hi"s abd,cted 4ith heels together- 5aise bed to a comfortable height<ash hands again and ",t glo)es on- Cay the to4el and dra"e o)er the "atient so the genitalia are ex"osedDrom here on, ,se yo,r non+dominant hand to hold the labia a"art, a""roaching the "atient from the right hand side, leaning o)er their ankles so as to reach the genitalia from belo4Clean the genitalia 4ith the 4et cotton balls =,sing each once only?, 4orking in a ",bis+ an,s directionCaref,lly "osition the no@@le of the l,bricant gel inside the meat,s and instilling most of the .mlPosition the bo4l bet4een the "atientHs thighs to catch s"illagesThe catheter 4ill be in a "lastic 4ra""er 4ith a tear+a4ay "ortion near the ti"- 5emo)e this "ortion, being caref,l not to to,ch the catheter and a""ly a little lidocaine gel to the catheter ti":nsert the ti" of the catheter into the ,rethral meat,s and ad)ance slo4ly b,t firmly by feeding it o,t of the remaining 4ra""erOn entering the bladder, ,rine sho,ld start to drain- ;d)ance the catheter f,lly to ens,re the balloon is beyond the ,rethra:nflate the balloon 4ith the !&ml of saline )ia the catheter side+arm"atient to alert yo, to any "ain and 4atch her face5emo)e the syringe and 4ithdra4 catheter ,ntil resistance is felt;ttach draining t,be and catheter bagClean and redress the "atient as necessary5ecord the resid,al ,rinary )ol,me<arn the

P-G%O

Dig- !'-A' 6iagrammatic re"resentation of the female external genitalia sho4ing "osition of the ,rethral meat,sHints ome female "atients are easier to catheteri@e in a different "osition012lying on their side 4ith knees raised =seek ex"erienced hel"? Cack of ,rine drainage may be ca,sed by: blockage of gel, em"ty bladder or catheter mis"lacement

;ttem"t to as"irate ,rine ,sing a catheter+ti""ed syringe- Deel for a f,ll bladder- :f there is any do,bt abo,t the "osition of the catheter, remo)e immediately =deflating balloon first? and seek senior ad)iceCom"lications:
o o o

Pain:nfectionMis"lacement and tra,ma-

0IJ Xe4are latex allergyY

<e thank Cyn 6ean for her hel" 4ith the "re"aration of this "ageP-GA&

,"ra",bic catheteri@ation

Theory ,"ra",bic catheteri@ation is sometimes seen as a safer and more efficient means of controlling bladder drainage than ,rethral catheteri@ation012"artic,larly if the "atient has had treatment or s,rgery in)ol)ing the )agina, ,rethra, ,reter, or "rostate- Patients often find this more acce"table than ,rethral catheteri@ation- ;lso, it allo4s the assessment of 4hen the "atient is able to )oid s"ontaneo,sly0124itho,t ha)ing to remo)e =and "ossibly re"lace? a ,rethral catheterThe catheter is inserted directly into the bladder, thro,gh the abdominal 4all /,st s,"erior to the ",bic sym"hysis- afe "lacement ,nder local anaesthesia re3,ires a )ery f,ll bladderThe "roced,re belo4 relates to the 018Xonanno019 ,"ra",bic kit- The essentials of the techni3,e 4ill remain the same for other catheteri@ation systems altho,gh small details may differ012refer to the "ack instr,ctionsMany ,rologists c,rrently fa)o,r the Xard ;ddacath systemE3,i"ment Trolley ! Xonanno ,"ra",bic catheter "ack =contains ",nct,re needle, catheter 4ith slee)e and ada"tor clam"?

! drainage bag:odine or antise"tic sol,tion% Z[ !&ml syringes.+!&ml !> lidocaine! green needle! orange needleterile "ack =containing glo)es, s4ab, and container?Dine, non+absorbable s,t,re-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Position the "atient s,"ine 4ith genitalia ex"osed- 5aise bed to a comfortable height

(n4ra" all the e3,i"ment onto a trolley in an ase"tic fashion and "o,r antise"tic sol,tion o)er the cotton ballsXefore commencing, make s,re that the "atient has a "al"able bladder- :f not, distend the bladder 4ith .&&+'&&ml of saline sol,tion instilled )ia a ,rethral catheter =if ,rethral ro,te a)ailableFfeasible?0IJ :f the bladder is not f,ll "roceed no f,rtherP,t on sterile glo)es, "re" the s,"ra",bic area 4ith antise"tic sol,tion-

The "oint of insertion is in the midline, % finger+breadths abo)e the ",bic sym"hysis and 4ell belo4 the ,""er edge of "al"able bladder;ssemble the Xonanno catheter com"onents =see Dig- !'-AL?;d)ance the catheter slee)e along the co,rse of the radio+o"a3,e catheter from a "roximal "osition ad/acent to the s,t,re disc to the distal end of the catheter to allo4 straightening of the coiled catheter:nfiltrate the insertion area 4ith the lidocaineP-GA!

Caref,lly insert the !L+ga,ge ",nct,re needle into the catheter so that the heel of the needle be)el is directed along inside the c,r)e of the catheter and mo)e in a clock4ise direction012,ntil the be)el extends beyond the catheter ti" =Dig- !'-AL?lide the straightener slee)e off the distal end of the catheterMras" the catheter needle WOcm abo)e the distal end and, 4ith a firm thr,st, ",sh the needle thro,gh the abdominal 4all012heading in a slightly ca,dal direction012,ntil yo, feel resistance disa""earCheck the "osition of the catheter in the bladder by remo)ing the black )ent "l,g and as"irate ,rine ,sing a !&ml syringe6isengage needle from the catheter h,b and ad)ance catheter ,ntil the s,t,re disc is flat against the skin<ithdra4 needleConnect ada"tor+clam" to the catheter h,b and sec,rely attach the r,bber "ortion of the clam" into a standard drainage catheter bagCaref,lly s,t,re the catheter into the abdominal 4all012yo, may also need to a""ly f,rther ta"e to ens,re the catheter 4onHt fall o,tEns,re the clam" is o"en to allo4 ,rine to drain=Y? :t may be easier to ,se a scal"el to make a small stab incision before inserting the needle-

Hints

Dig- !'-AL :nserting the needle into the c,r)ed catheterP-GA%

Xasic s,t,ring Theory Xasic s,t,ring, or stitching, has many "ractical a""lications o,tside the field of s,rgery<hether yo, are called ,"on to s,t,re a central line in "lace or are stitching ," a laceration, itHs a skill yo, sho,ld "ractise before yo, need to ,se it- There are many ,sef,l texts and articles 4hich describe in more detail the fine art of s,t,ring and 4e 4o,ld refer yo, to these- (ndo,btedly, the best 4ay to learn is by 4atching a s,rgeon and then doing it yo,rself- :n most clinical skills labs yo, sho,ld find the necessary e3,i"ment in order to "ractise these skillsE3,i"ment Trolley 6ressing "ack

%!+ga,ge green needle%.+ga,ge orange needle!&ml and %&ml syringesMa,@e;ntise"tic sol,tion,t,res =selection de"ending on the site and nat,re of the 4o,nd?Ta"eterile glo)es-

har"s binToothed force"sNeedle holdercissorscal"el-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Dirst assess the 4o,nd and decide on the si@e of the s,t,re materialo

5emember that there are alternati)e 4ays to achie)e 4o,nd clos,re s,ch as gl,e, sta"les and steri+stri"s- ;l4ays consider the most a""ro"riate means of closing a 4o,nd-

Xefore s,t,ring, irrigate the 4o,nd, and remo)e any foreign bodies and any non+)iable or infected tiss,e(se a needle holder s,ch as toothed force"s 4here "ossible, to minimi@e the risk of needlestick in/,ryHold the needle %FA of the 4ay from the needle ti"Cift the skin edge farthest a4ay 4itho,t "inching or damaging itPierce the skin 4ith the needle at O&#P5otate yo,r 4rist to "ass the needle into the middle of the 4o,nd5elease the force"s and clas" the needle again as it "rotr,des into the 4o,nd, rotating it o,t of the 4o,ndNext "ress the near side 4ith the closed force"s to e)ert the skin edge, and "ass the needle thro,gh, taking a smooth semicirc,lar co,rse to exit at O&#P to the 4o,nd edgeee Dig- !'-AOThis method ens,res a s3,are bite and good e)ersion of the 4o,ndNo4 "erform a s,rgeonHs knoto

<ra" the long end of the thread aro,nd the force"s, 4hich is ,sed to transfer the coil aro,nd the short end =grab the short tail and ",ll in to4ards yo,, ",lling the long end a4ay?5e"eat the cycle-

P-GAA

5emember to c,t the ends of the thread off, lea)ing a fe4 mm so that they can be easily remo)ed later-

0IJ <hen remo)ing s,t,res, clean the 4o,nd 4ith antise"tic sol,tion, ,se force"s or a blade and ",ll the s,t,re o,t across rather than a4ay from the 4o,ndThe time taken to remo)e non+absorbable s,t,res de"ends on the location: Dace: .+' days cal": '+!& days

Cimbs and tr,nk: !%+!B days-

Dig- !'-AO 6iagrammatic re"resentation of the stages in)ol)ed in a basic s,t,reP-GAB

C,mbar ",nct,re Theory ; needle is introd,ced bet4een the l,mbar )ertebrae at a le)el belo4 the termination of the s"inal cord- :t then "asses thro,gh the d,ra into the s,barachnoid s"ace and a sam"le of cerebros"inal fl,id is obtained(sed for diagnostic and thera"e,tic ",r"oses too n,mero,s to list-

E3,i"ment terile glo)es terile "ack =containing dra"e, cotton balls and container?

;ntise"tic sol,tionterile ga,@e dressing.+!&ml !> lidocaine% Z[ !&ml syringeXiochemistry t,be for gl,coseOrange needleMreen needleCP needleCP manometerA+4ay ta" =may be incl,ded in CP kit?A sterile collection t,bes-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Position the "atient lying on their left+hand side 4ith the neck, knees and hi"s flexed as m,ch as "ossible =if able, the "atient may be asked to clas" their hands aro,nd their knees?- P,t a "illo4 bet4een the "atientHs knees to "re)ent the "el)is tilting =see Dig!'-B&?

Ens,re that the "atient can hold this "osition comfortably:dentify the iliac crest012the disc s"ace )ertically belo4 this =as yo, are looking? 4ill be WCA+CBMark the s"ace bet4een the )ertebral s"ines 4ith a "en<ash hands and ",t on sterile glo)es(n4ra" all e3,i"ment and ens,re it fit together correctly;""ly the dra"es aro,nd the area and sterili@e 4ith the antise"tic sol,tion and cotton balls in o,t4ard+s"iral motions:n/ect the lidocaine =,sing a !&ml syringe and the orange needle? at the marked site to raise a small 4heal-

4a" the orange needle for the green one and infiltrate the lidocaine dee"er- Take care to as"irate before in/ecting to ens,re blood )essels are a)oided<ait for W! min,te for the anaesthetic to take effect:ntrod,ce the s"inal needle =%%M ,s,ally? thro,gh the marked site at abo,t O&#P to the skin, heading slightly to4ard the ,mbilic,s- Kee" the be)el facing ," the "atientHs s"ineMently ad)ance the needle thro,gh the ligaments =to W.cm de"th?;t this "oint, a f,rther ",sh of the needle sho,ld "rod,ce a 018gi)e019 as the needle enters the s,barachnoid s"ace =this takes a little "ractise to feel 4ith confidence?:f, at any "oint, the needle strikes bone and cannot be ad)ance, 4ithdra4 slightly, re+ angle and ad)ance in a ste"4ise fashion ,ntil the ga" is fo,ndP-GA.

<ithdra4 the stilette from the needle 01U C D sho,ld begin to dri" o,tMeas,re the C D "ress,re012connect the manometer to the end of the needle )ia the A+ 4ay ta" =the C D 4ill rise ," the manometer allo4ing yo, to read off the n,mber?O"en the ta" and allo4 the C D to dri" into the A collection t,bes012abo,t . or G dri"s "er t,be- The t,bes sho,ld be labelled 018!019, 018%019, and 018A019, in order of collection- Collect a fe4 more dri"s into the biochemistry t,be for gl,cose meas,rement5e"lace the stilette and remo)e the needle- ;""ly a sterile dressingend the fl,id for analysiso o o

Cell co,nt =bottles ! and A?Microsco"y, c,lt,re and sensiti)ities =bottles ! and A?Xiochemistry: gl,cose, "rotein =bottle %?-

;d)ise the "atient to lie flat for W! ho,r and ask n,rsing staff to check CN obser)ations at least t4ice d,ring that time;l4ays ,se the smallest ga,ge s"inal needle a)ailable:f the "atient s,ffers a se)ere or "rolonged headache after the "roced,re, it may be "ossible to in/ect W%&mC of )eno,s blood into the CP site to "rod,ce a 018blood "atch019012ask for seniorFanaesthetic ad)iceY

Hints

Dig- !'-B& Correct "osition of the "atient for a l,mbar ",nct,reP-GAG

Pericardial as"iration Theory Emergency "ericardial as"iration =drainage of fl,id from the "ericardial ca)ity? may be "erformed in cardiac tam"onade or large "ericardial eff,sions 4here there is haemodynamic com"romise- This "roced,re can also be ,sed to obtain diagnostic "ericardial fl,idE3,i"ment terile go4n and glo)es ;ntise"tic sol,tion

terile to4els!&ml syringe.&ml syringeThree+4ay ta"ECM monitoring, defibrillator and res,scitation e3,i"mentCocal anaestheticNeedles!L+ga,ge cann,la-

Proced,re :f conscio,s, introd,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Establish :7 access and connect ECM monitor 4ith f,ll res,scitation e3,i"ment to hand-

Pro)ide ade3,ate sedation if necessaryP,t sterile glo)es and go4n:f time "ermits, ,se local anaesthesia to infiltrate the insertion site;ttach the !L+ga,ge cann,la to the .&ml syringe:ntrod,ce needle at B.#P to the skin immediately belo4 and to the left of the xi"histern,m to a de"th of G+Lcm, in a direction aiming for the ti" of the sca",la;s"irate contin,o,sly and 4atch the ECMo

:f the needle to,ches the )entricle an in/,ry "attern =de"ressed T segment? or arrhythmia may be seen0124ithdra4 the needle slightly-

;s"irate "ericardial fl,id thro,gh the syringe and A+4ay ta";s"iration sho,ld "rod,ce immediate haemodynamic im"ro)ementEo, can check if the fl,id yo, are as"irating is ",re blood if it clots 3,ickly- Hea)ily bloodstained "ericardial fl,id does not clotPerform a C\5 and echocardiogram after the "roced,reEo, may 4ish to insert a "ericardial drain =seek senior ad)ice?6oc,ment the details of the "roced,re in the notes-

Possible com"lications Pne,mothorax ;rrhythmia

Myocardial ",nct,re6amage to the coronary arteries-

P-GA' P-GAL

6efibrillation Theory Electrical defibrillation is the only effecti)e thera"y for cardiac arrest ca,sed by )entric,lar fibrillation =7D? or ",lseless )entric,lar tachycardia =7T?- The 5es,scitation Co,ncil =(K? strongly recommends a "olicy of early attem"ted defibrillation- This is beca,se the chances of s,ccessf,l defibrillation decline at a rate of '+!&> 4ith each min,te of delay-

:n the hos"ital setting, % ty"es of defibrillator may be enco,ntered: the traditional man,al defibrillator and the ne4er a,tomated external defibrillators =;E6?There are t4o ty"es of ;E6: most are semi+a,tomatic and ad)ise the need for a shock, b,t this has to be deli)ered by the o"erator 4hen "rom"ted- ome also ha)e the facility to enable the o"erator to o)erride the de)ice and deli)er a shock man,ally, 4itho,t any "rom"ts- ; fe4 f,lly a,tomatic ;E6s are also a)ailableE3,i"ment 6efibrillator Mel "adsProced,re for man,al defibrillation =Dig- !'-B%? 4itch on the defibrillator, ens,re the skin is dry and free of excess hair ;ttach the ECM electrodes accordingly:
o o o

5ed ,nder right cla)icleEello4 ,nder left cla)icleMreen at the ,mbilic,s-

;scertain that the ECM rhythm is shockable =7DF",lseless 7T?Place the defibrillation gel "ads on the "atientHs chest:
o o

One /,st to the right of the stern,m, belo4 the cla)icleThe other /,st lateral to the cardiac a"ex-

ha)e chest hair only if it is excessi)e and 4ill interfere 4ith electrical contactelect AG&J on the defibrillatorPlace the "addles firmly on the gel "ads on the gel "adsPress the charge b,tton on the "addles to charge the defibrillator and sho,t 018stand clear012charging019Check that all staff ha)e ste""ed back =incl,ding yo,rself? and that no+one is to,ching the "atient or their bed by caref,lly looking0IJ Ens,re high flo4 oxygen has also been remo)ed0IJ Check the monitor again to ens,re a shockable rhythmho,t 018stand clear012shocking019 and "ress both discharge b,ttons sim,ltaneo,sly to discharge the shockDollo4 the "rotocol o)erleaf012ret,rn the "addles to the defibrillator before contin,ing 4ith CP5-

P-GAO Proced,re for ;E6s =Dig- !'-BA? 4itch on the defibrillator, ens,re the skin is dry and free of excess hair and attach the electrode "ads =same "osition as the gel "ads in man,al defibrillation o""osite? Contin,e CP5 4hile this is done if more than one assistant "resent

Make s,re no one is to,ching the "atient d,ring ECM analysis by the ;E6Dollo4 the )oice "rom"tso

These are ,s,ally "rogrammable and the 5es,scitation Co,ncil =(K? recommends that they be set as follo4s: ; single shock only 4hen a shockable rhythm is detectedNo rhythm, breathing, or ",lse check after the shock; )oice "rom"t for immediate res,m"tion of CP5 after the shockT4o min,tes allo4ed for CP5 ,sing a ratio of A& com"ressions to % resc,e breaths before a )oice "rom"t to assess the rhythm, breathing, or a ",lse is gi)en-

o o o o

0IJ :f a shock is indicated sho,t 018stand clear019 and "erform )is,al checks to ens,re no "ersonnel are in contact 4ith the "atient or their bed and that any oxygen has been remo)edP,sh the shock b,tton and contin,e as directed-

Dig- !'-B! Correct "osition of the gel "ads or ;E6 electrodes on the "atient- Ens,re that they are not to,ching or o)erlying any 4ires, oxygen t,bing or any other cond,cting material- Ens,re that the "atientHs chest is dry and sha)ed if "artic,larly hairyP-GB&

Dig- !'-B% ;lgorithm for ad)anced life s,""ort ,sing a man,al defibrillator- 5e"rod,ced 4ith "ermission from the 5es,scitation Co,ncil =(K? g,idelinesP-GB!

Dig- !'-BA ;E6 algorithm- 5e"rod,ced 4ith "ermission from the 5es,scitation Co,ncil =(K? g,idelinesP-GB%

Knee /oint as"iration Theory :n the context of a s4ollen /oint, a /oint as"iration is "erformed for both diagnostic =to identify infectio,s and crystal arthro"athies? and thera"e,tic =to relie)e tense eff,sions and haemarthroses? ",r"oses; sam"le of fl,id may be remo)ed and sent for microsco"y, c,lt,re and sensiti)ity in addition to being examined for crystals ,nder "olari@ed light- ee table sho4ing im"ortant diagnostic feat,res of /oint as"irates in Cha"ter !LThis same "roced,ral a""roach may be ,sed for /oint in/ections =e-g- steroids and local anaesthetic to s,""ress inflammation?E3,i"ment .+!&ml !> lidocaine ! Z[ %&ml syringe

! Z[ .ml syringe! Z[ %!+ga,ge =green? needle! Z[ %.+ga,ge =orange? needle;ntise"tic sol,tionterile bottlesterile glo)es6ressing "ack 4ith cotton balls-

Proced,re :ntrod,ce yo,rself, confirm the identity of the "atient, ex"lain the "roced,re, and obtain )erbal consent Ens,re that the "atient is relaxed and lying comfortably on the co,ch or bed 4ith the knee ex"osed and slightly flexed

Pal"ate the o,tline of the "atella and the medial /oint line =as"iration is easier on the medial side?<ash yo,r hands and don a "air of sterile glo)esClean the site 4ith the cotton balls and antise"tic sol,tion:nfiltrate the insertion site 4ith local anaesthetic- (se !+%ml of !> lidocaine ,sing the %.+ga,ge orange needle and a .ml syringe- 5emember to as"irate before in/ectingTake a %&ml syringe and attach a %!+ga,ge green needle-

:nsert the needle at an angle of aro,nd B.#P in the ga" bet4een the lo4er border of the "atella and the medial /oint line:f the needle is in the /oint s"ace =abo,t %cm in?, yo, sho,ld be able to freely as"irate syno)ial fl,id- ;s"iration can be aided by "ressing on the o""osite side of the /oint 4ith yo,r free handOnce the syringe is f,ll, remo)e it from the /oint and transfer the fl,id into sterile s"ecimen bottlesend to microbiology for microsco"y, c,lt,re and sensiti)ity and a f,rther sam"le to the biochemistry de"artment to look for crystalsDollo4ing as"iration, ask the "atient to rest the knee for %B+BL ho,rs5ecord in the notes the "roced,ral details incl,ding the colo,r of the syno)ial fl,id and the in)estigations re3,ested-

P-GBA

Dig- !'-BB ;s"iration of the knee /oint012insert the needle at abo,t B.#P heading distally belo4 the "atella-