Clinical Skills Finall 2011

Front 1

asepsis

Back 1

absence of infection. no pathogenic microorganisms on body surfaces or animate surfaces...goal is to contain confine reduce or eliminate microorganisms

Front 2

can you sterilize skin?

Back 2

no

Front 3

nonsterile persons must maintain distance of?

Back 3

18 inches and not reach over sterile areas.

Front 4

operating room attired

Back 4

personal hygiene, scrubs washed in hospital, cover all facial hair, shoe covers, masks, gowns, gloves, side shields w/ eye protection

Front 5

if sterility of an item is in question what do you do?

Back 5

always consider it contaminated

Front 6

tables are sterile only at?

Back 6

table height

Front 7

sterile area of clothing?

Back 7

axilla to wasit frontal plane, fingertips to 3 inch above the elbow. contact w/ sterile goods to a minimum; moisture carries bacteries

Front 8

hand scrubbing

Back 8

removes debris, reduce resident microbial count on the skin, inhibit rapid rebound growth of micro-orgganisms; nails short unpolished no artificial nails
no open wounds
no jewelry
--brushless handrub-90% alcohol shortens surgical scrub time <3 mins less irritation, inc compliance; must do an initial hand wash prescrub each morning
100 count method
dry hand held higher than elbows

Front 9

shave prep done when?

Back 9

immediately before surgery to prevent pustules
Nair is best or skin clippers

Front 10

how to do scrub prep

Back 10

from center of incisional site and work outward

Front 11

types of sterilization of goods and supplies

Back 11

kills all froms of living material
moist heat is most common autoclave
dry heat
ethylene oxide (gas) instruments that can't stand steam
--kills all forms of living matter

Front 12

disinfect hospital environment by?

Back 12

chemicals on inanimate surgaces like op room floor

Front 13

disinfect means vs antisepsis

Back 13

chemicals on inanimate surfaces

antisepsis on animate objects

Front 14

environmental control of op room

Back 14

traffic control greater air pressure inside; controlled room temp 68, controlled humidity 50%

Front 15

patietns more susceptible to post-op wound infections?

Back 15

diabetics, obese, RA anything debilitating;
pt factors contributing to infecction are dehydration, shock uremia, controlled DM, malnutrition, anemia, obesity, meds

Front 16

clean wounds

Back 16

clean are elective closed, undrained, non traumatic uninfected no inflammation, no break in aseptic technique; resp, GI, GU, oro tracts NOT entered; only 4% develop infection; no prophylactic antibiotic needed

Front 17

when to start prophalatic Ab?

Back 17

contaminated wounds
dirty/infected wounds (technically treatment)

Front 18

clean contaminated wounds

Back 18

entered GI resp GU or oro tarct but not infected urine or bile; minor break in aseptic technique (hole in glove), mech drainage necessary
w/o Ab 4-8% get infected

Front 19

contaminated wounds

Back 19

open freash traumatic, spillage from GI; enter GU/bililary infected urine bile; major break aseptic tech; incisions w/ acute non-purulent inflammation
20% prophylactice antibiotic use is indicated

Front 20

dirty or infected wounds

Back 20

traumatic wound w/ retained devitalized tissue; foreign body; focal contam; delay treatment, from dirty source (perforated ulcer), abscess, perforated viscus, acute bact inflmammtion w/ pus!!!
w/o treatment 50% get infection; antibiotic treatment is indicated NOT prophylaxis (perforated gastric ulcer, acute diverticulitis w/ peri-colonic abscess)

Front 21

minor break in aseptic tecnique?

Back 21

clean-contaminated wound

Front 22

common causes of abdominal pain

Back 22

inflammation obstruction perforation hemorrhage

Front 23

acute pancreatitis always doing what?

Back 23

moving around to find position of comfort

Front 24

PE of abodmen in order

Back 24

inspect, auscultate, percuss palpate

Front 25

McBurney's sign

Back 25

rebound tenderness ASIS and umbilicus=appendicitis; mass effect that moves stool in colon

Front 26

appendicitis how?

Back 26

fecalith blocks appendix--.>swells-->inflammaed-->peritonitis-->if perforation relief form pain but fluid can affect entire pelvis

Front 27

murphy's sign

Back 27

RUQ under ribs arrest breat; acute cholescytitis

Front 28

time diagnosis is made in rhematology in an H&P?

Back 28

80-90%

Front 29

most cost effective labs for RA?

Back 29

CMB, CMP, sed

Front 30

risk factors for post op wound infection?

Back 30

Dehydration
Shock
Uremia
Uncontrolled diabetes
Malnutrition
Anemia
Obesity
Medications (steroids)

Front 31

skin prep agents

Back 31

Iodinated compounds (iodophors)- Betadine, Duraprep Chlorhexidine (Hibiclens)-Hexachlorophene (Phisohex) -Ethyl alcohol

Front 32

atrial line placement indications

Back 32

Hemodynamic monitoring
Frequent blood sampling
Rx administration
Intra-aortic balloon pump use
mech ventilated pts
limited vneous access

monitor arterial blood or blood sampling

Front 33

test performed to access perfusion of radial arterial

Back 33

allen or modified allen test <5 seconds >15 seconds

Front 34

complications of arterial line placement

Back 34

thrombosis MC

Front 35

why never force needle back into cannula?

Back 35

sheer off the catheter tip

Front 36

MC sides for art line placement

Back 36

radial (unleess in shock); femoral and brachial in code; axillary, dorsalis pedis and kids temporal arteries

Front 37

why need to assess collateral circulation before line placement

Back 37

needed to maintain viability of distal tissues if thrombosis occurs

Front 38

position wrist in arterial line placement by?

Back 38

30-60 degress angle; dorsiflex

Front 39

seldinger technique?

Back 39

arterial line guidwirde w/ needle to help put in catheter

Front 40

indications of chest tube

Back 40

pneumothorax, hemopneumothroax, empyema, chylothorax pleural effusion

Front 41

CI of chest tube

Back 41

absolute uncooperative pt, lack of experience, coagulopathies, can't see rib site
relative--lung disease, PEEP, lung elevated L diaphram SM, L pleural effusion

Front 42

steps before chest tube inserted

Back 42

pt must be evaluated thorough ly by pe and chest films to avoid insertion of tube into bulla or lung abscess or into wrong side

Front 43

improtanc eof SQ tunnel during tube placement

Back 43

discourages air entry into the chest following removal o the tube
use a kelly clamp to help open

Front 44

best location for chest tube?

Back 44

4th or 5th intercostal space in the anterior axillary line

Front 45

inject local anesthetic for chest tube?

Back 45

2 fingerbreaths below intercostal spacd; aspirate FIRST to prevent injection into intercostal vessels

Front 46

complicatons of chest tube and thoracocentesis

Back 46

tube into vital structures, bleeding, residual pneumothorax, reexpansion of pumonary edema

Front 47

seldinger technique

Back 47

after initial puncture is made by a hollow needle, a guidewire is inserted, which allows a blunt cannula to be passed over the guide wire
o allows for much safer angiography

Front 48

indications of diagnostic peritoneal lavage?

Back 48

Blunt abdominal trauma: unexplained hypotension/blood loss
Penetrating Abdominal Trauma
Evaluating for Possible Peritonitis
Therapeutic (hypothermic re-warming; delivery of Rx)

Front 49

CI of diagnostic peritoneal lavage DPL

Back 49

Absolute: laparotomy is already indicated
Relative: Pregnancy, Morbid obesity, Prior abd surgery, Retroperitoneal injury, cirrhosis

Front 50

preferred insertion side of DPL?

Back 50

intraumbilical catheter angled at 45 degree angle
1/3 disance from umbilicus to pubic bone, inject w/ epineprhine

Front 51

complications of DPL

Back 51

intra-abdominal organ injury, malposition of lavage catheter, iatrogenic hemoperitoneum, infection
oInadequate return of lavage effluent

Front 52

closed percutaneous technique in DPL

Back 52

similar to “catheter-over-needle” technique seen in paracentesis
o Needle is inserted into peritoneal cavity, with two pops heard (linea alba then peritoneum)
o Guidewire is passed through the needle, then the catheter is inserted for lavage
o attach a syringe to ALWAYS aspirate for blood (to rule out for “an obvious hemoperitoneum”); if no blood returns, use 1L normal saline to instill into the peritoneal cavity
o requires 300ml return lavage fluid for a representative sample

Front 53

semi closed DPL

Back 53

: similar to closed method, except the fascia is directly visualized
o A vertical incision is made infraumbilically, then small retractors are used to pull apart the sub-Q tissue; keep making serial incisions until rectus fascia is visualized
o proceed then with closed technique
used with a catheter needle

Front 54

why is semiopen tecnique better than closed for DPL

Back 54

safer and more accurate

Front 55

open technique DPL

Back 55

same as semiopen except peritoneal cavity is opened under direct visualization
o used when the above two methods are not successful
o Dissect down through midline abd wall as in SemiOpen, except make larger incision through the rectus fascia …
o make small nick in peritoneum just large enough to slide in DPL catheter alone

Front 56

trocar method of DPL

Back 56

Advantage: speed - catheter placement and aspiration generally done in 5 minutes
• Disadvantage: hollow visceral injury/vascular penetration
• General method:
o made to utilize percutaneously … puncture the peritoneum (pop sound)
o Trochar advanced just 0.5cm more, then ONLY the catheter is advanced further, then remove trochar

Front 57

how findings influence treatment plan of DPL

Back 57

Positive Results
o RBC > 100,000 / ml or
o WBC > 500 / ml or
o Amylase > 175

Front 58

why do DPL?

Back 58

determine if they are bleeding
10mL of blood is positive

Front 59

indications of a central venous line?

Back 59

Central venous pressure monitoring, total parenteral nutrition, longterm drug infusion, hypovolemic patient
o poor peripheral venous access
o note: volume resuscitation alone is NOT an indication for CVC

Front 60

what is not an indication alone for CVL?

Back 60

voulmen resusciation

Front 61

contrications for CVL

Back 61

Venous thrombosis, coagulopathy, untreated sepsis, uncooperative patient, overlying skin or soft tissue infection, marked obesity (relative CI), multiple previous catheterizations at same site

Front 62

sites for CVL?

Back 62

Subclavian: most reliable site in shock/hypovolemia (remains patent due to clavicle fibrous attachments)
o Internal Jugular: direct path to right ventricle – good for emergency transvenous pacemakers
o Femoral: excellent route during CPR, or if patient unable to lay supine
“NAVEL”: femoral vein lies medial to the femoral artery

Front 63

subclavian and IJV CVL?

Back 63

Supine in Trendelenburg (15-30 degree) position, NO pillow
o Place towel roll vertically bt scapulae and beneath the thoracic vertebrae; arms should be at the side
o allow patient’s shoulders to fall down and back
o important for infraclavicular subclavian vein approach: have assistant apply traction on ipsilateral arm in an inferior direction toward foot
o Turn patient’s head away from side of line placement

Front 64

most reliable site for CVL?

Back 64

subclavian

Front 65

good for emergency pacemakers CVL?

Back 65

IJV

Front 66

complications of CVL?

Back 66

hematoma, air embolism, catheter malposition, vein thrombosis, pneumothorax, misdirected cannula, cardiac dysrhythmias …

Front 67

femoral CVL?

Back 67

supine, with HOB elevated 20-30 degrees
o place ipsilateral hip in slight external rotation

Front 68

CI of biopsy?

Back 68

melanoma (use excisional),
 inflammatory dermatoses (ex: pyoderma gangrenosum);
 overlying anatomic structures (facial nerve, tendons, fingers)
 subcutaneous lesions not reachable with punch biopsy
 foot/toe lesions in those with peripheral vascular disease

Front 69

complications of biopsy?

Back 69

excessive bleeding (punctured vessel or clotting defect)
• so avoid over superficial vessels, or use Epinephrine also
 infection
 hypertrophic scar or keloid formation (esp in sites subject to tension)

Front 70

tru cut biopsy?

Back 70

Indication: differentiates benign and malignant lesions
o Contraindications: coagulopathy
o Complications: bleeding, hematomas, infections

Front 71

what can differentiate b/n benign or malignant lesions?

Back 71

tru cut and exhisional

Front 72

abdominal paracentesis

Back 72

Indications
o Diagnostics and Therapeutics
• Contraindications: coagulopathy, thrombocytopenia, infected skin, bowel obstruction, pregnancy (relative)
• Complications:
o Hypotension (rapid mobilization of fluid from intravascular space)
o hemorrhage
o bowel perf
o persistent ascites leak
o bladder perf
• Steps to take PRIOR to placement:
o percuss possible entry sites to confirm fluid presence and absence of underlying bowel
o patient should empty bladder, or cath the patient

Front 73

subrapubic cysostomy

Back 73

Indications: inability to cath in the setting of acute urinary retention
o Urethral disruption due to pelvic trauma
o bladder drainage required in presence of urethral or prostatic infection
o bladder drainage for urethral operations
• Contraindications: non-distended, non-palpable bladder
o prior midline infraumbilical incision
o coagulopathy
o pregnancy, carcinoma of bladder, pelvic irradiation
• Complications
o bowel injury – bladder not distended, improper needle position
 note: bladder MUST be distended and palpable for this
o hematuria – due to laceration of submucosal vessel or rapid decompression of chronically distended bladder
 so, gradually decompress the distended bladder

Front 74

cricothyroidectomy

Back 74

Indications: orofacial trauma preventing laryngoscopy,  upper airway obstruction,  unsuccessful endotracheal intubation,  need for emergent airway
o Absolute Contraindications-- ability to safely intubate the patient,  transaction of the trachea
 fracture of the larynx
 laryngotracheal disruption
o Relative CI
 children less than 8-12 yo
 bleeding problems
o note: in children, a Needle Cricothyroidotomy is preferred technique in order to avoid damage to the cricoids cartilage, however, this ventilation lasts only about 30-45 minutes

Front 75

what is preferred to air flow procedue in children?

Back 75

needle cricothyroidectomy

Front 76

difficulties for chricothyroidectomy

Back 76

Intraoperative Bleeding: prevent by incising directly over cricothyroid membrane
• Late Bleeding: prevent by packing/suturing
• Tracheostomy tube will not enter trachea: prevent by making incision adequate size and spreading dilator widely; have more than one size tube available
• Air leakage past trach tube: prevent by selecting appropriate size and for leaks beforehand; inflate balloon with minimal amount of air to overcome leak
• Occluded Trach tube: prevent by not overinflating cuff; suction patients as needed
• Tracheal stenosis at cuff site: prevent with a low pressure type cuff
• Infection: rare
• Esophageal Injury: prevent by keeping incision superficial, and stopping once the cricothyroid membrane is incised