CLINICALCLINICAL SESSIONSSESSIONS 20102010
'Handbook of Clinical Procedures'
Compiled and led by
Shan Keshri
Manuals created by:
Shan Keshri, Devangna Bhatia, Bhavin Doshi, Shilpa Nelapatla,
Nathan Golban, Dave Utulu, Richard Dolan, Arjun Keshri, Sada Chatzialis,
Joae de Oliveira, Amit Kaushal, Pooja Mithani, Diogo Forjaz, Mubarak Al-Rasheedi
Kumaran Thanabalasingham, Nikos Lymberopoulos, Michalis Ploumidis
Teaching Room courtesy of: MIMSA
Clinical Sessions was a 6 week course (09.03.10 – 13.04.10) run ‘by the students, for the
students’ at the Faculty of Medicine, Masaryk University, Brno.
As promised in the first session introduction, this is the ‘Handbook of Clinical Procedures’.
It is the result of the efforts of the students.
Sincere thanks to everyone who took part, be it by preparing and presenting a topic, or by
attending. I believe it was a huge success, and feel these notes are an invaluable reference
source.
As this is the efforts of fellow students, please be understanding if you find any mistakes.
Do however, be assured all efforts were made to make the information as accurate and as
up-to-date as we could manage.
Once again thanks to all that took part,
Good Luck,
Shan Keshri
Preface
Pooja
Sada
Michalis
Richard
Mubarak
Nikos
Bhav
Shan
Devangna
Joae Dave
Shilpa
Nathan Amit Arjun
Diogo Kumaran
SESSION 1 (Blood & Urine procedures)
1) Taking a Patient History
Devangna Bhatia
2) Phlebotomy (taking blood)
Shan Keshri
3) Interpreting Blood Results (Heamatology, Biochemistry, Lipids, Enzymes)
Shan Keshri & Amit Kaushal
4) Urine Collection, Urinalysis
Shan Keshri
5) Cathethers and Cannulas (IV situations)
Bhavin Doshi
6) Common Drugs used to treat common respiratory disorders
Shan Keshri
SESSION 2 (Obs / Gynae)
1) Arterial Blood Sampling
Nathan Golban
2) Obs n Gynae Intro, Breast examination
Arjun Keshri & Sada Chatzialis
3) Pregnancy Test
Arjun Keshri & Sada Chatzialis
4) IM & SC injections. Insulin injection techniques
Pooja Mithani
5) Pelvic examination & Cervical Pap Smear
Shan Keshri
SESSION 3 (GIT)
1) Abdominal examination
Amit Kaushal & Kumeran Thanabalasingham
2) Nasogastric tube insertion
Shan Keshri
3) First Aid overview
Devangna Bhatia
4) Central Venous Catheterisation
Shilpa Nelapatla
5) Sutures
Joae de Oliviera
SESSION 4
1) Rectal examination
Nikos Lymberopoulos
2) Otoscopy & Opthalmoscopy
Shan Keshri
3) Urethral Catheterisation (male & female)
Diogo Forjaz
4) GALS (gait, arm, leg, spine) & joint exam
Dave Utulu
SESSION 5 (Neuro, Cardiac)
1) Neurological examination (cerebellar, cranial nv, reflexs)
Shan Keshri
2) CSF Examination
Michalis Ploumidis
3) Drainage Tubes (application and removal)
Devangna Bhatia
4) Normal chest xray (things to check)
Mubarak Alrasheedi
5) ECG (signs of heart disease)
Dave Utulu
SESSION 6 (Resp)
1) Respiratory Function Tests (peak flow, spirometry, manual ventilation)
Dave Utulu
2) Airway Intubation (inc. simple adjuncts e.g. Guedal airway/ laryngeal masks)
Joae de Oliviera
3) Administration of oxygen therapy (via a face mask or other equipment)
Richard Dolan
4) Using a Nebuliser / Inhaler correctly
Richard Dolan
*Due to technical problems, CSF Examination and Chest X-Ray Manuals are not included.
WELCOME TOWELCOME TO
CLINICAL SESSIONSCLINICAL SESSIONS
AIMAIM –– Quick reference guidesQuick reference guides
 Resource ofResource of ‘‘clinical manualsclinical manuals’’ = quick reference to= quick reference to
know step by step method and core principlesknow step by step method and core principles
 NonNon--practical topics = train our minds to thinkpractical topics = train our minds to think
differential diagnoses and treatmentsdifferential diagnoses and treatments
 Results of urinalysis show low urea level. What could thisResults of urinalysis show low urea level. What could this
indicate?indicate?
 Patients suffers from heart failure. What is the first linePatients suffers from heart failure. What is the first line
drugs classes; what are some names of preferred Bdrugs classes; what are some names of preferred B--
Blockers used in hospitals / UK today?Blockers used in hospitals / UK today?
 Learn or revise via weekly interactive presentationsLearn or revise via weekly interactive presentations
 Q&A discussions, videos, roleQ&A discussions, videos, role--play, props, anything toplay, props, anything to
illustrate the conceptsillustrate the concepts
Why is it important to know theseWhy is it important to know these
things now?things now?
 They are based on theThey are based on the ‘‘basic learning outcomes of medicalbasic learning outcomes of medical
schoolschool’’, set out by the GMC UK., set out by the GMC UK.
 When applying for your 1When applying for your 1stst
job, thejob, the ‘‘Clinical SkillsClinical Skills’’ section ofsection of
form asks: Can you confidently do the following proceduresform asks: Can you confidently do the following procedures
Yes or No?Yes or No?
DonDon’’t only concentrate on the coret only concentrate on the core
principles!principles!
 UK students have OSCE practical exams. If theyUK students have OSCE practical exams. If they
forget to wash their hands or forget to checkforget to wash their hands or forget to check
patient identity before even touching the patientpatient identity before even touching the patient
they lose marks!!they lose marks!!
 So to maintain this standard, Safety, infectionSo to maintain this standard, Safety, infection
control and communication reminders will also becontrol and communication reminders will also be
included in the presentations .included in the presentations .
 We only have time to study the clinical side ofWe only have time to study the clinical side of
things.things.
 With regards to the textbook science, we canWith regards to the textbook science, we can
make references to the key words, to give you amake references to the key words, to give you a
starting point needed to read further.starting point needed to read further.
Any questions before we getAny questions before we get
started?started?
HISTORY TAKINGHISTORY TAKING
Devangna
Bhatia
INTRO
• A.k.a anamnesis
• An accurate history is the biggest step in making 
the correct diagnosis.
• The main aim of history taking is to find out what 
caused the patient to come to the surgery and 
seek help. 
• Then it is our job, as doctors, to use this 
information and formulate a diagnosis and 
provide the medical care needed.
• The more detail you can get, the better and 
easier it will be for you to come up with a 
diagnosis.
Before taking a history…
• Put the patient at ease – developing a good 
relationship with the patient will help
• Shake hands, introduce yourself
• Check whether the patient is comfortable
• Have a conversational tone rather than an 
interrogative one – it will make the patient feel 
more comfortable and that (s)he can tell you more 
information
While taking the history, keep in mind…
• Don’t interrupt the patient while (s)he is talking, 
let them finish and then ask the questions…
• Show that you are paying attention even while 
writing – nodding, occasionally looking up and 
making eye contact, or the occasional “yes, ok”
• Don’t forget to write the date (& time)!
• If you ask about any malignancies in the family, 
you need to be tactful!
• Keep in mind the religion of the patient and be 
tactful, so as you don’t look ignorant when 
asking some questions
Taking the history…
1) Start with general questions : name, age, 
DOB, occupation, martial status
2) Presenting Complaint (PC): “What has been 
the trouble recently?”
This is the complaint that caused them to seek 
medical help.
Use the patient’s wording, when noting it down, 
rather than medical terms…
3) History of Presenting complaint (HPC): “When 
did it begin? What was the first thing you 
noticed? Have you had it before?”
Site
Onset – gradual or sudden
Character – sharp, dull, thumping, constant…
Radiation
Associations (sweating, nausea…)
Timing of pain/duration/frequency
Exacerbating and alleviating factors
Severity (scale of 1 to 10, or comparing it to child 
birth)
4) Direct questioning (DQ): specific questions 
about the diagnosis you have in mind (+ its risk 
factors), e.g. if you suspect the patient may have 
malaria, ask them about their travel history, 
what they may have consumed…
5) Past Medical History (PMH): ever been in 
hospital? Illnesses, especially childhood ones. 
Operations? Diabetes, asthma, bronchitis, TB, 
jaundice, hypertension, rheumatic fever, heart 
disease, epilepsy, stroke, peptic ulcer, 
anaesthetic problems.
Also, ask here about allergies – penicillin, dogs, 
cats, hay fever, dust…
6) Drug History (DH): taking any tablets, 
injections? “off the shelf” drugs, e.g. cough 
syrup? The pill, herbal remedies? 
7) Social History (SH): martial status? Live alone? 
Any help at home? House or apartment? What 
does the illness prevent the patient from doing? 
Occupation? Sexual history – their attitude 
towards it…
8) Family History (FH): age, health and cause of 
death of parents, siblings and children. Diseases 
such as hypertension, diabetes, or malignancies 
in the family
9) Alcohol, Recreational drugs, tobacco: How much? 
How often? When did you begin? When did you 
stop?
Express cigarettes in pack‐years: 20 cigarettes 
smoked per day for 1 year = 1 pack‐year
We all like to present ourselves in the good light, so 
be ready to double the stated quantities by the 
patient! 
The CAGE questionnaire can be used as a screening 
test for alcoholism (later on)
General problems ‐ weight loss, night sweats, any 
lumps, appetite, fever, recent trauma
Cardio‐respiratory symptoms – cough, sputum, 
wheeze, haemoptysis, oedema, chest pain, 
dyspnoea, orthopnoea
Gut symptoms – abdominal pain, haematemesis 
swallowing, ingestion, nausea/vomiting, bowel 
habit, stool – colour, consistency, blood
Functional enquiry: to uncover un‐declared 
symptoms…
Genitourinary Symptoms – incontinence, dysuria, 
haematuria, nocturia, frequency, polyuria, 
hesistancy
FEMALES: vaginal discharge, menses: freq, 
regularity, painful, heavy/light, first day of last 
menstrual period (LMP), menarche, menopause, 
no. of pregnancies, any chance of pregnancy 
right now?
Neurological Symptoms – special senses – sight, 
hearing, taste & smell; seizures, faints, poor 
balance, headaches, weakness, “pins and needles”, 
speech problems, sphincter problems
Important thing to do, is assess function: what can 
and can’t the patient do at home, work etc.
Musculoskeletal symptoms – pain, stiffness, swelling 
of joints; functional deficit; diurnal variation in 
symptoms (i.e. with time of day)
CAGE Questionnaire
Been used for a long time, as a screening test for 
alcoholism
2 or more positive answers = alcohol problem
C: have you ever felt you should cut down on your 
drinking?
A: have you ever been annoyed at others’ concerns 
about your drinking?
G: have you ever felt guilty about drinking?
E: have you ever had alcohol as an eye‐opener in 
the morning?
Definitions
• Haemoptysis ‐ coughing up blood
• Dyspnoea – breathlessness
• Orthopnoea ‐ breathlessness while lying flat
• Haematemesis ‐ vomiting blood
• Incontinence – stress or urge
• Dysuria – painful micturition
• Haematuria – bloody micurition
• Nocturia – needing to micturate at night
• Polyuria – passing excessive amounts of urine
• Hesitancy – difficulty starting micurition
• Menarche – the first menstrual period, usually occurring 
during puberty
• Menopause ‐ the period of permanent cessation of 
menstruation, usually occurring between the ages of 45 and 
55. 
VENEPUNCTURE:VENEPUNCTURE:
PHLEBOTOMYPHLEBOTOMY
SHAN KESHRISHAN KESHRI
Clinical Sessions 2010Clinical Sessions 2010
akaaka
BLOOD COLLECTIONBLOOD COLLECTION
INDICATIONSINDICATIONS
DiagnosticDiagnostic::
•• Obtain blood sample for analysis.Obtain blood sample for analysis.
(e.g. systemic problems(e.g. systemic problems –– Fe anemia, glucose DM,Fe anemia, glucose DM, INR,INR,
infections, cholesterol, immunology, liver enzymes/ function)infections, cholesterol, immunology, liver enzymes/ function)
INDICATIONSINDICATIONS
TherepeuticTherepeutic::
•• treat Polycythemia Veratreat Polycythemia Vera (elevated RBC volume(elevated RBC volume
aka hematocrit)aka hematocrit)
•• treat hemochromatosistreat hemochromatosis (dangerously high iron(dangerously high iron
levels)levels)
•• Donation for transfusionDonation for transfusion
CONTRAINDICATIONSCONTRAINDICATIONS
 Low oxygen levels in bloodLow oxygen levels in blood
(hypoxemia)(hypoxemia)
RISKSRISKS
 InfectionInfection
 negligible if sterile environment, propernegligible if sterile environment, proper
use/disposal of needles, and proper management ofuse/disposal of needles, and proper management of
samples.samples.
 Hitting a nerve or arteryHitting a nerve or artery (arterial stab)(arterial stab)
 remove needle and apply pressureremove needle and apply pressure
SIDE EFFECTSSIDE EFFECTS
 Some pain, possible bruisingSome pain, possible bruising
 Fainting and light headed (Fainting and light headed (vasovaso--vagalvagal))
 Excessive bleedingExcessive bleeding
 HaematomaHaematoma (blood acc. under skin)(blood acc. under skin)
 Iron deficiency anemiaIron deficiency anemia (in therapeutic phlebotomy)(in therapeutic phlebotomy)
ALTERNATIVESALTERNATIVES
 No real alternative to phlebotomy, however thereNo real alternative to phlebotomy, however there
are various different sites on the body that couldare various different sites on the body that could
be used.be used.
 See Method.See Method.
 Never attempt more than twice:Never attempt more than twice:
•• Refer patient back.Refer patient back.
PROCEDUREPROCEDURE
Think Action & Rationale!
WHAT are you doing? WHY are you doing it?
At every
step know:
WASH HANDSWASH HANDS
EQUIPMENT: Sterile Tray with:EQUIPMENT: Sterile Tray with:
 Pair of glovesPair of gloves
 TourniquetTourniquet
 Alcohol wipesAlcohol wipes
 GauzeGauze
 VACUTAINER barrel and NeedleVACUTAINER barrel and Needle
 Blood bottlesBlood bottles (color coded according to additive e.g.(color coded according to additive e.g.
anticoagulant or preservative)anticoagulant or preservative)
RULES OF ASEPSISRULES OF ASEPSIS
STEP 2: CHECK PATIENT DETAILSSTEP 2: CHECK PATIENT DETAILS
 Ask fullAsk full NameName,, DOBDOB,, GenderGender and compareand compare
with blood request form!with blood request form!
 Check blood form has beenCheck blood form has been signedsigned by theby the
requesting doctorrequesting doctor
 IfIf special requirementsspecial requirements, check patient has, check patient has
complied, e.g. fasting!complied, e.g. fasting!
 Have you had blood taken before?Have you had blood taken before? (preferred(preferred
vein)vein)
PutPut GlovesGloves on.on.
Ensure patient is in a relaxed position.Ensure patient is in a relaxed position.
FIND A SUITABLE VEINFIND A SUITABLE VEIN
(Palpation: bouncy & large & superficial)(Palpation: bouncy & large & superficial)
 90% used90% used –– AnteriorAnterior CubitalCubital FossaFossa,,
–– MedianMedian CubitalCubital vein, Cephalic,vein, Cephalic, BasilicBasilic VeinVein
 Back of handBack of hand-- Cephalic (Cephalic (housemanshousemans) vein) vein
 Feet, Central Line, Peripheral Venous line,Feet, Central Line, Peripheral Venous line,
Femoral stab (groin harder to disinfect)Femoral stab (groin harder to disinfect)
 Attach VACUTAINER needle to barrel.Attach VACUTAINER needle to barrel.
 Apply tourniquet 2 fingers aboveApply tourniquet 2 fingers above
anterioranterior cubitalcubital fossafossa.. (increases pressure)(increases pressure)
Inform patientInform patient ‘‘this may feel a little tightthis may feel a little tight’’..
 Disinfect skin with alcohol wipes.Disinfect skin with alcohol wipes.
 Remove cap from needle.Remove cap from needle.
 Warn Patient of Sharp Scratch.Warn Patient of Sharp Scratch.
 Stretch skin and insert needle atStretch skin and insert needle at
1515--30 degrees parallel30 degrees parallel into the veininto the vein
(bevel edge(bevel edge ofof needleneedle facingfacing upup))
15-30 degrees
 Introduce VACUTAINER bottle intoIntroduce VACUTAINER bottle into
the barrel.the barrel.
 Allow blood to collect. It willAllow blood to collect. It will
automatically stop filling when full.automatically stop filling when full.
 NB: DifferentNB: Different colourcolour bottles contain differentbottles contain different
additives and antiadditives and anti--coagulants etc!coagulants etc!
 Amount drawn depends on indicationAmount drawn depends on indication
(see request form)(see request form)
 However normallyHowever normally 55--25 ml25 ml isis
enough.enough.
 FIRST Remove blood BOTTLEFIRST Remove blood BOTTLE
 THEN remove TOURNIQUETTHEN remove TOURNIQUET
 LASTLY, swiftly remove NEEDLELASTLY, swiftly remove NEEDLE
 Safely dispose needle to sharps binSafely dispose needle to sharps bin
immidiatelyimmidiately ––NEVER RESHEATH!!NEVER RESHEATH!!
 Apply gauze to puncture site for 1Apply gauze to puncture site for 1
minute, with some pressure.minute, with some pressure.
 Remove gloves and wash handsRemove gloves and wash hands
MANAGEMENTMANAGEMENT
 Invert blood bottle to ensure bloodInvert blood bottle to ensure blood
mixes with the additives in specimenmixes with the additives in specimen
bottlebottle
Label blood bottle:Label blood bottle:
 Patient NamePatient Name
 Identification NumberIdentification Number
 Date & TimeDate & Time ……etcetc
 Document in patient record.Document in patient record.
 Send to Pathology lab for analysis.Send to Pathology lab for analysis.
WASH HANDSWASH HANDS
OLD UKOLD UK / CURRENT CZ METHOD/ CURRENT CZ METHOD
 MONOVETTE SARSTEDT VACUUM TUBESMONOVETTE SARSTEDT VACUUM TUBES
 Pull syringe to create vacuum, then slot into needle.Pull syringe to create vacuum, then slot into needle.
 When full, snap off handleWhen full, snap off handle
To PreventTo Prevent HeamatomaHeamatoma!!
 PuncturePuncture onlyonly thethe uppermostuppermost wallwall ofof thethe veinvein
 EnsureEnsure needlneedlee fullyfully penetratespenetrates uppermostuppermost wallwall ofof
thethe veinvein.. ((PartialPartial penetrationpenetration maymay allowallow bloodblood toto leakleak))
 RemoveRemove tourniquettourniquet beforebefore removingremoving needleneedle
(decreases pressure)(decreases pressure)
 Use majorUse major superficialsuperficial veinsveins
 ApplyApply pressurepressure toto thethe puncturepuncture sitesite
Protect Yourself!Protect Yourself!
(in addition to what has been mentioned)(in addition to what has been mentioned)
 Change gloves between patients.Change gloves between patients.
 Clean up spills with disinfectant.Clean up spills with disinfectant.
 Do notDo not breakbreak,, oror rerecap needle.cap needle.
((avoidavoid accidentalaccidental needleneedle puncturepuncture oror splashingsplashing ofof contentscontents))
Protect Yourself!Protect Yourself!
(in addition to what has been mentioned)(in addition to what has been mentioned)
 In Event of being pricked with needle:In Event of being pricked with needle:
•• RemoveRemove and dispose of gloves.and dispose of gloves.
•• SqueezeSqueeze puncturepuncture sitesite toto promotepromote bleedingbleeding..
•• WashWash areaarea wellwell withwith soapsoap andand waterwater..
•• RecordRecord thethe patientpatient’’ss namename andand IDID numbernumber..
•• FollowFollow institutioninstitution’’ss guidelinesguidelines regardingregarding treatmenttreatment andand
followfollow--upup..
NB PNB Prophylacticrophylactic zidovudinezidovudine followingfollowing bloodblood exposureexposure to HIV hasto HIV has
shownshown effectivenesseffectiveness..
SUMMARYSUMMARY
 TTourniquetourniquet
 AAntiseptic wipentiseptic wipe
 PPalpatealpate
 IInsernsertt
 ........ but be gentle!but be gentle!
 DonDon’’t forget Safety and Communication.t forget Safety and Communication.
VIDEOVIDEO
THANKYOU FOR LISTENINGTHANKYOU FOR LISTENING
http://www.youtube.com/user/vanitagoss#p/a/u/1/9http://www.youtube.com/user/vanitagoss#p/a/u/1/9
V_5Dgr9ozMV_5Dgr9ozM
Overview:Overview:
INTERPRETATION OFINTERPRETATION OF
BLOOD RESULTSBLOOD RESULTS
SHAN KESHRISHAN KESHRI
Clinical Sessions 2010Clinical Sessions 2010
(Hematology)(Hematology)
We will consider results ofWe will consider results of
Full / Complete Blood CountFull / Complete Blood Count
(FBC / CBC)(FBC / CBC)
 HAEMATOLOGYHAEMATOLOGY
 BIOCHEMISTRYBIOCHEMISTRY
 LIPIDSLIPIDS
 CARDIAC ENZYMESCARDIAC ENZYMES
 OTHEROTHER
----------------------------------------------------------
1 Unit Blood = just under 1 pint (450ml)1 Unit Blood = just under 1 pint (450ml)
 Average Body contains 8Average Body contains 8--10 pints10 pints
11 MAIN HAEMATOLOGICAL11 MAIN HAEMATOLOGICAL
VALUESVALUES
(1) WBC (Leukocyte) COUNT(1) WBC (Leukocyte) COUNT
 FUNCTION: Immune cells, fight infectionFUNCTION: Immune cells, fight infection
Derived from Bone MarrowDerived from Bone Marrow
 NORMAL :NORMAL : 4.34.3 -- 10.8 x 1010.8 x 10**99 /L/L
 HIGH =HIGH = LeukocytosisLeukocytosis
•• Infection?Infection?
•• Malignancy? Leukemia?Malignancy? Leukemia?
 LOW = LeucopeniaLOW = Leucopenia
•• Bone MarrowBone Marrow probprob??
•• Chemotherapy treatment?Chemotherapy treatment?
 28% Lymphocytes : Fight infection28% Lymphocytes : Fight infection
 HIGH : Infection?, Leukemia?HIGH : Infection?, Leukemia?
 LOW : Chemo?, Radiation?, Stress?LOW : Chemo?, Radiation?, Stress?
 Granulocytes:Granulocytes:
•• 3%3% EosinophilsEosinophils –– Allergic reactionsAllergic reactions
 Low : Steroids?Low : Steroids?
•• 65%65% NeutrophilsNeutrophils / 5%/ 5% MonocytesMonocytes –– Primary responsePrimary response
 High : AcuteHigh : Acute inflaminflam?, Malignancy??, Malignancy?
 Low : Chemo?, AI?, BMLow : Chemo?, AI?, BM probprob??
 0.5%0.5% BasophilsBasophils
(2) WBC DIFFERENTIAL COUNT(2) WBC DIFFERENTIAL COUNT
 FUNCTION : O2 Transport. Derived from Bone marrow,FUNCTION : O2 Transport. Derived from Bone marrow,
(large bones)(large bones)
 NORMAL : 4.2NORMAL : 4.2 –– 5.9 x 10*9 /L5.9 x 10*9 /L
 HIGHHIGH
•• Low O2 (hypoxia) ?Low O2 (hypoxia) ? --> Inc. Erythropoietin> Inc. Erythropoietin
(hormone that stimulates RBC production)(hormone that stimulates RBC production)
 LOWLOW –– AnemiaAnemia
•• Iron/Iron/ VitVit. B12 Deficiency? etc.. Refer to. B12 Deficiency? etc.. Refer to PathophysPathophys!!
•• Bone Marrow diseaseBone Marrow disease
 Most common blood cell / smaller than WBC , larger thanMost common blood cell / smaller than WBC , larger than
platelets / Lifetime approx 120 days.platelets / Lifetime approx 120 days.
(3) RBC(3) RBC (erythrocyte)(erythrocyte) COUNTCOUNT
(4) HEMOGLOBIN ((4) HEMOGLOBIN (HbHb))
 FUNCTION : Protein within RBC, O2 transport vehicle. GivesFUNCTION : Protein within RBC, O2 transport vehicle. Gives
blood redblood red colourcolour..
 NORMAL MALE : 13.5NORMAL MALE : 13.5 –– 16.916.9 g/dLg/dL (M av. 15.2)(M av. 15.2)
 NORMAL FEMALE : 11.5NORMAL FEMALE : 11.5 –– 14.814.8 g/dLg/dL (F av. 13.2)(F av. 13.2)
HEMOGLOBIN (HEMOGLOBIN (HbHb) cont.) cont.
 LOW : AnemiaLOW : Anemia
 Blood Loss?Blood Loss?
 Nutritional (iron, b12,Nutritional (iron, b12, folatefolate) def. ?) def. ?
 BMBM probprob??
 Chemotherapy?Chemotherapy?
 Kidney failure?Kidney failure?
 Sickle cell anemia? /Sickle cell anemia? / ThallasemiaThallasemia (hereditary(hereditary
lowlow HbHb))
 HIGH :HIGH :
 High altitudes?High altitudes?
 Smoker?Smoker?
 Dehydration?Dehydration?
(5) HEMATOCRIT ((5) HEMATOCRIT (HctHct))
 measured via RBC sedimentationmeasured via RBC sedimentation –– spin blood sospin blood so
RBCRBC’’ss settlesettle
 WHAT : % RBC volume relative to total blood volume.WHAT : % RBC volume relative to total blood volume.
 NORMAL MALE : 45NORMAL MALE : 45 –– 52 % (M av. 49%)52 % (M av. 49%)
 NORMAL FEMALE : 37NORMAL FEMALE : 37 –– 48 % (F av. 43%)48 % (F av. 43%)
HEMATOCRIT (HEMATOCRIT (HctHct))
 LOW :LOW :
 Anemia?Anemia?
 Blood Loss?Blood Loss?
 Nutritional Def.?Nutritional Def.?
 BMBM probprob??
 Chemotherapy?Chemotherapy?
 Sickle cell anemia?Sickle cell anemia?
 HIGH :HIGH :
 Erythropoietin abuse (athlete doping) ?Erythropoietin abuse (athlete doping) ?
 High altitude ?High altitude ?
 Smoker ?Smoker ?
 Dehydration ?Dehydration ?
(6) MEAN CORPUSCULAR(6) MEAN CORPUSCULAR
VOLUME (MCV)VOLUME (MCV)
 WHAT : Average vol. of RBCWHAT : Average vol. of RBC
(calculated from(calculated from HctHct / RBC count)/ RBC count)
 NORMAL: 80NORMAL: 80––100100 femtofemto--litreslitres
(fraction of one millionth of a(fraction of one millionth of a litrelitre))
(7) MEAN CORPUSCULAR(7) MEAN CORPUSCULAR
HEMOGLOBIN (MCH)HEMOGLOBIN (MCH)
 WHAT : Average amount ofWHAT : Average amount of HbHb in RBCin RBC
 NORMAL MALE : 45NORMAL MALE : 45 –– 52 % (M av. 49%)52 % (M av. 49%)
 NORMAL FEMALE : 37NORMAL FEMALE : 37 –– 48 % (F av. 43%)48 % (F av. 43%)
(8) MEAN CORPUSCULAR(8) MEAN CORPUSCULAR
HEMOGLOBIN CONC (MCHC)HEMOGLOBIN CONC (MCHC)
 WHAT : AverageWHAT : Average HbHb concconc in a given volume of RBCin a given volume of RBC
 NORMAL : 32NORMAL : 32 –– 36 %36 %
(9) RED CELL DISTRIBUTION(9) RED CELL DISTRIBUTION
WIDTH (RDW)WIDTH (RDW)
 WHAT : Measurement of variability of RBCWHAT : Measurement of variability of RBC
size & shapesize & shape
 NORMAL : 11NORMAL : 11 –– 1515
 Higher valueHigher value –– More VariationMore Variation
(10) PLATELET COUNT(10) PLATELET COUNT
 FUNCTION : Role in clotting, Bleeding control.FUNCTION : Role in clotting, Bleeding control.
 NORMAL 150NORMAL 150 –– 400 x 10*9 /L400 x 10*9 /L
 LOW = ThrombocytopeniaLOW = Thrombocytopenia
 Prolonged bleeding?Prolonged bleeding?
 Drug toxicity?Drug toxicity?
 HIGH =HIGH = ThrombocytosisThrombocytosis
 Bone MarrowBone Marrow probprob??
(11) MEAN PLATELET(11) MEAN PLATELET
VOLUMEVOLUME
 WHAT : Average size of plateletsWHAT : Average size of platelets
 PANCYTOPNEA : Low WBC, RBC &PANCYTOPNEA : Low WBC, RBC &
PlateletsPlatelets
•• Bone MarrowBone Marrow ProbsProbs
OtherOther HaematologicalHaematological ref valuesref values
 VitVit. B12 : 179. B12 : 179 –– 11621162
 SerumSerum FolateFolate : 2.7: 2.7 –– 3434
 FerritinFerritin : 10: 10 –– 204 :iron store204 :iron store
 PT Time : 10PT Time : 10 –– 13 seconds :clotting?13 seconds :clotting?
 Fibrinogen : 1.5Fibrinogen : 1.5 –– 4.5 g/L4.5 g/L
 INR : 2INR : 2--4 :coagulation therapy4 :coagulation therapy
 APTT Activated partialAPTT Activated partial thromboplastinthromboplastin time : 30time : 30--40s40s
•• Test of intrinsicTest of intrinsic coagcoag. factor deficiency.. factor deficiency.
SUMMARYSUMMARY
1.1. WBCWBC :: 4.34.3 -- 10.8 x 1010.8 x 10**99 /L/L
2.2. WBC DIFFERENTIAL :WBC DIFFERENTIAL : 28%28% LypLyp/ 3%/ 3% EosinophilsEosinophils/ 65%/ 65% NeutrophilsNeutrophils/ 5%/ 5%
MonocytesMonocytes/ 0.5%/ 0.5% BasophilsBasophils
3.3. RBCRBC : 4.2: 4.2 –– 5.9 x 10*9 /L5.9 x 10*9 /L
4.4. HbHb:: M : 45M : 45 –– 52 %, F : 3752 %, F : 37 –– 48 %48 %
5.5. HctHct :: M : 45M : 45 –– 52 % F : 3752 % F : 37 –– 48 %48 %
6.6. MCVMCV : 80: 80––100100 femtofemto--litreslitres
7.7. MCH :MCH : M : 45M : 45 –– 52 % F : 3752 % F : 37 –– 48 %48 %
8.8. MCHCMCHC : 32: 32 –– 36 %36 %
9.9. RDWRDW : 11: 11 –– 1515
10.10. PLATELETSPLATELETS : 150: 150 –– 400 x 10*9 /L400 x 10*9 /L
FURTHER READINGFURTHER READING
 Thrombin TimeThrombin Time
 APTTAPTT
 Coagulation screening testsCoagulation screening tests
 Platelet aggregation testsPlatelet aggregation tests
 EuglobulinEuglobulin clotclot lysinglysing time (ELT)time (ELT)
 Thrombotic diseasesThrombotic diseases
 Diseases of Blood and Bone MarrowDiseases of Blood and Bone Marrow
 AnaemiasAnaemias,, ThallassemiaThallassemia,, Splenomegaly,HaemophiliaSplenomegaly,Haemophilia andand
coagulation disorderscoagulation disorders
 History taking in relation to Blood disorders (presentingHistory taking in relation to Blood disorders (presenting
symptoms)symptoms)
Overview:Overview:
INTERPRETATION OFINTERPRETATION OF
BLOOD RESULTSBLOOD RESULTS
SHAN KESHRI & AMIT KAUSHALSHAN KESHRI & AMIT KAUSHAL
Clinical Sessions 2010Clinical Sessions 2010
(Biochemistry, Lipids,
Enzymes & Other)
BIOCHEMICAL VALUESBIOCHEMICAL VALUES
BIOCHEMICAL VALUES
 Sodium : 136Sodium : 136 –– 145145 mmolmmol/L/L
 Potassium : 3.5Potassium : 3.5 –– 5.15.1 mmolmmol/L/L
 Urea: MUrea: M –– 3.23.2 –– 7.4 / F7.4 / F –– 2.52.5 –– 6.76.7
 CreatinineCreatinine : 53: 53 –– 115115 µµmol/Lmol/L
 GFR:GFR:
 HbA1c : 4.3HbA1c : 4.3 –– 6.1% : Insulin therapy6.1% : Insulin therapy
 Glucose (random) : 4.0Glucose (random) : 4.0 –– 7.8mmol/L7.8mmol/L
 Fasting Glucose : 3Fasting Glucose : 3--6mmol/L6mmol/L
 Bilirubin : 0Bilirubin : 0--2020 µµmol/Lmol/L
 ALT: 10ALT: 10--30 (IU/L)30 (IU/L)
 ALP: 39ALP: 39--128 (IU/L)128 (IU/L)
 Albumin : 35Albumin : 35--50 g/L50 g/L
 Magnesium : 0.7Magnesium : 0.7--11 mmolmmol/L/L
 Phosphate : 0.74Phosphate : 0.74 --1.521.52 mmolmmol/L/L
 Calcium : 2.2Calcium : 2.2 -- 2.62.6 mmolmmol/L/L
NaNa++
(136(136 –– 145145 mmolmmol/L)/L)
•• Mostly ECFMostly ECF
•• Controlled by RASControlled by RAS
•• LowLow NaNa++
–– Signs and Symptoms: Seizures, Cardiac Failure,Signs and Symptoms: Seizures, Cardiac Failure,
DehydrationDehydration
–– Causes: Vomiting, Diuretics, AddisonCauses: Vomiting, Diuretics, Addison’’s Disease, Lows Disease, Low
ADH, Renal FailureADH, Renal Failure
–– Management:Management: Correct underlying cause, not theCorrect underlying cause, not the
[Na[Na++ ] alone] alone
–– Acute Situation: Saline infusion and FurosemideAcute Situation: Saline infusion and Furosemide
•• HighHigh NaNa++
–– Signs and symptoms: Thirst, Hypertension,Signs and symptoms: Thirst, Hypertension,
Dehydration, Fits, OliguriaDehydration, Fits, Oliguria
–– Causes:Causes: HH220 loss0 loss (without Iron loss, eg. Vomiting &(without Iron loss, eg. Vomiting &
Diarrhea )Diarrhea ) DiabetesDiabetes insipidusinsipidus (ADH intolerance)(ADH intolerance)
–– Management:Management: HH220 administration0 administration
KK++
3.53.5 –– 5.15.1 mmolmmol/L/L
•• Mostly ICFMostly ICF
•• Exchanges with HExchanges with H++ acrossacross membmemb..
•• Insulin/Insulin/CatecholaminesCatecholamines stimulate Kstimulate K ++ uptake intouptake into
cellscells
•• HighHigh KK++
::
»» Signs and Symptoms: Cardiac arrhythmiasSigns and Symptoms: Cardiac arrhythmias
(sudden death)(sudden death)
»» ECG: WIDE QRS ComplexECG: WIDE QRS Complex
»» Causes: Diuretics, AddisonCauses: Diuretics, Addison’’s Disease, Mets Disease, Met
Acidosis, Burns, ACE InhibitorsAcidosis, Burns, ACE Inhibitors
»» Management: Treat underlying causeManagement: Treat underlying cause
»» Emergency Treatment: Insulin and GlucoseEmergency Treatment: Insulin and Glucose
admin. (IV)admin. (IV)
•• Low KLow K++::
»» S & S: Muscle weakness, crampsS & S: Muscle weakness, cramps
»» ECG: Depressed ST SegmentECG: Depressed ST Segment
»» Causes: Diuretics,Causes: Diuretics, ConnConn’’ss Syndrome,Syndrome,
Alkalosis. High ACTH productionAlkalosis. High ACTH production
»» Management: KManagement: K++ supplements, IV Ksupplements, IV K++
Do not give KDo not give K++
ifif oliguricoliguric
Glucose: 4.0Glucose: 4.0 –– 7.87.8 mmolmmol/L/L
•• Fasting: 3.0Fasting: 3.0--6.06.0 mmolmmol/L/L
•• Post eating (Post eating (pranadialpranadial): <10): <10 mmolmmol/L/L
•• High GlucoseHigh Glucose
»» Causes: DM Type I & II, CushingCauses: DM Type I & II, Cushing’’s Syndrome,s Syndrome,
PhaeochromocytomaPhaeochromocytoma,,
»» Treatment: Insulin therapy (I) and Diet therapy (II)Treatment: Insulin therapy (I) and Diet therapy (II)
»» Diagnosis:Diagnosis: oGTToGTT
•• Low GlucoseLow Glucose
»» Causes: ECauses: E--PLAIN (Exogenous drugs (insulin), PituitaryPLAIN (Exogenous drugs (insulin), Pituitary
Insuff., Liver Failure, Addison's, Islet cell tumour, nonInsuff., Liver Failure, Addison's, Islet cell tumour, non--
pancreatic neoplasm)pancreatic neoplasm)
»» Treatment: Oral Glucose/Long acting starch (toast)Treatment: Oral Glucose/Long acting starch (toast)
»» Diagnosis: FingerDiagnosis: Finger--prick testprick test
Bilirubin : 0Bilirubin : 0--2020 µµmol/Lmol/L
PrePre--hepatichepatic:: HighHigh
unconjugated bilirubinunconjugated bilirubin
(hemolysis)(hemolysis)
IntraIntra--hepatichepatic:: Hepatitis,Hepatitis,
Cirrhosis, CarcinomaCirrhosis, Carcinoma
PostPost--hepatichepatic:: HighHigh
conjugated bilirubinconjugated bilirubin
(biliary obstruction(biliary obstruction--
stones, pancreatitis)stones, pancreatitis)
ALT: 10ALT: 10--30 (IU/L)30 (IU/L)
ALP: 39ALP: 39--128 (IU/L)128 (IU/L)
Increase = marker of a diseaseIncrease = marker of a disease
•• High ALPHigh ALP;;
•• Causes: Liver disease (bile duct block), Bone diseaseCauses: Liver disease (bile duct block), Bone disease
(high activity e.g. Paget(high activity e.g. Paget’’s disease)s disease)
•• High ALTHigh ALT;;
•• Causes: Liver damage (hepatitis), InfectiousCauses: Liver damage (hepatitis), Infectious
mononucleosis,mononucleosis, BiliraryBilirary duct obstructionduct obstruction
AST:ALT > 2 = Alcoholic hepatitisAST:ALT > 2 = Alcoholic hepatitis
AST:ALT < 1 = Viral hepatitisAST:ALT < 1 = Viral hepatitis
Albumin : 35Albumin : 35--50 g/L50 g/L
•• High AlbuminHigh Albumin;;
»» Causes: DehydrationCauses: Dehydration
»» S & S: WIKI itS & S: WIKI it……
•• Low AlbuminLow Albumin;;
»» S & S:S & S: OedemaOedema
»» Causes:Causes: NephroticNephrotic Syndrome, Liver disease,Syndrome, Liver disease,
BurnsBurns
Magnesium : 0.7Magnesium : 0.7--11 mmolmmol/L/L
•• 65% in bone & 35% within cells65% in bone & 35% within cells
•• High MgHigh Mg::
–– S & S: Neuromuscular depression and CNSS & S: Neuromuscular depression and CNS
depressiondepression
–– Dg: Renal failure ?Dg: Renal failure ?
•• Low MgLow Mg::
–– Dg: Diarrhea ?Dg: Diarrhea ? KetoacidosisKetoacidosis ??
CaCa2+2+
: 2.2: 2.2 -- 2.62.6 mmolmmol/L/L
•• Control of CaControl of Ca2+2+::
–– PTH,PTH,
–– Vitamin D (Kidney, GIT, Skin)Vitamin D (Kidney, GIT, Skin)
–– CalcitoninCalcitonin
•• High CaHigh Ca2+2+::
–– S & S:S & S: ‘‘bones stones groansbones stones groans’’,, AbdAbd. pain, Constipation. pain, Constipation
–– Dg: Primary PTHDg: Primary PTH--ism ?ism ? SarcoidosisSarcoidosis ??
–– Treatment: Diuretics, BiTreatment: Diuretics, Bi--phosphatesphosphates
•• Low CaLow Ca2+2+::
–– S & S:S & S: TetaniTetani, Depression, Facial muscle twitch,, Depression, Facial muscle twitch,
ChvostekChvostek signsign
–– Dg: Chronic renal failure ? Thyroid surgery ? LowDg: Chronic renal failure ? Thyroid surgery ? Low
Vitamin DVitamin D
–– Treatment: Calcium admin.Treatment: Calcium admin.
LIPID VALUESLIPID VALUES
LIPID VALUES
 Cholesterol : <5Cholesterol : <5 mmolmmol/L/L
 Triglyceride : <2Triglyceride : <2 mmolmmol/L/L
 HDL : >1HDL : >1 mmolmmol/L (good cholesterol)/L (good cholesterol)
 LDL : <3LDL : <3 mmolmmol/L/L
 HIGH LDL and LOW LDL = Increased risk of CHDHIGH LDL and LOW LDL = Increased risk of CHD
 High cholesterol can lead to AtherosclerosisHigh cholesterol can lead to Atherosclerosis
 Management: Lifestyle changes,Management: Lifestyle changes, StatinsStatins e.g. SIMVASTATINe.g. SIMVASTATIN
CARDIAC ENZYMESCARDIAC ENZYMES
CARDIAC ENZYMES
 CKCK--MBMB
 TroponinTroponin TT
 MyoglobinMyoglobin
 Markers of MI / Heart disease?Markers of MI / Heart disease?
OTHER VALUESOTHER VALUES
OTHER VALUES
 CRPCRP
 Markers of inflammation associated with acute phaseMarkers of inflammation associated with acute phase
responseresponse
 TSHTSH
 Hyperthyroidism (Graves disease, Thyrotoxicosis)Hyperthyroidism (Graves disease, Thyrotoxicosis)
 S & S: Sweating,S & S: Sweating, GoitresGoitres
 Hypothyroidism (HashimotoHypothyroidism (Hashimoto’’s disease, Iodines disease, Iodine
deficiencydeficiency
 S & S: Constipation, Mental retardation in Kids,S & S: Constipation, Mental retardation in Kids,
TirednessTiredness
Graves Disease
THANKYOU FOR LISTENING
URINE COLLECTIONURINE COLLECTION
SHAN KESHRISHAN KESHRI
Clinical Sessions 2010Clinical Sessions 2010
Rapid & Cost effectiveRapid & Cost effective
INDICATIONSINDICATIONS
 Diagnose / Screen:Diagnose / Screen:
–– Urinary Tract Infection?Urinary Tract Infection?
–– Presenting urinary symptoms : urgency?, frequency? etcPresenting urinary symptoms : urgency?, frequency? etc
–– Kidney Stones?Kidney Stones?
–– Kidney disease? e.g.Kidney disease? e.g. proteinuriaproteinuria inin nephrosisnephrosis??
–– Hydration status of patient with fluid lossHydration status of patient with fluid loss
–– Monitor disease progressions (DM :Monitor disease progressions (DM :glycosglycos && ketoketo--uriauria, HT), HT)
–– Early detection of substances or abnormalities of body (Early detection of substances or abnormalities of body (endoendo, met), met)
BEFORE BLOOD COMPONENTS AFFECTED!!BEFORE BLOOD COMPONENTS AFFECTED!!
PROCEDUREPROCEDURE
‘‘Clean catch, MidClean catch, Mid--Stream SpecimenStream Specimen’’
 Patient will do it themselves, so you mustPatient will do it themselves, so you must
explain to them properly what to do!explain to them properly what to do!
Clean CatchClean Catch
 Wipe external urethral opening clean withWipe external urethral opening clean with
cleansing wipe.cleansing wipe.
 DONDON’’T USE ALCOHOLIC WIPET USE ALCOHOLIC WIPE –– theythey
irritate!irritate!
 WOMEN : Then spread labia of externalWOMEN : Then spread labia of external
genetaliagenetalia, and wipe back to front., and wipe back to front.
RIGHT LEFT
MidMid--Stream CollectionStream Collection
 Start urinating initial stream into the toiletStart urinating initial stream into the toilet
(flush contaminants from outer urethra).(flush contaminants from outer urethra).
 Stop, then restart urinating, approx 10Stop, then restart urinating, approx 10--1515
ml in the provided sterile specimenml in the provided sterile specimen
container (till full),container (till full), akaaka Midstream.Midstream.
 Remaining urine can be voided into toilet.Remaining urine can be voided into toilet.
 Bottle returned to requesting physicianBottle returned to requesting physician
(check labeling)(check labeling)
 If immediate analysis not possible, sampleIf immediate analysis not possible, sample
should be refrigerated.should be refrigerated.
ManagementManagement
ALTERNATIVESALTERNATIVES
 Patient with urinary (Foley) catheter:Patient with urinary (Foley) catheter: analyseanalyse the urine inthe urine in
the bagthe bag
 Children not toilet trained : Attach collection bag toChildren not toilet trained : Attach collection bag to
external genital region.external genital region.
 Comatose/ confused patient : Urine collection by catheterComatose/ confused patient : Urine collection by catheter
 SupraSupra--pubic transpubic trans--abdominal needle for aspiration ofabdominal needle for aspiration of
urinary bladder (purest specimen)urinary bladder (purest specimen)
NOTESNOTES
 Female specimens may contain vaginal componentsFemale specimens may contain vaginal components
e.g.e.g. trichomonadstrichomonads, yeast, RBC during menstruation, yeast, RBC during menstruation
 Early morning sample preferred; before ingestion ofEarly morning sample preferred; before ingestion of
any fluid is usually hypertonic and reflects ability ofany fluid is usually hypertonic and reflects ability of
the kidney to concentrate urine during dehydrationthe kidney to concentrate urine during dehydration
which occurs overnight.which occurs overnight.
 If all fluid ingestion has been avoided since 6 p.m.If all fluid ingestion has been avoided since 6 p.m.
the previous day, the specific gravity usually exceedsthe previous day, the specific gravity usually exceeds
1.022 in healthy individuals.1.022 in healthy individuals.
URINALYSIS (UA)URINALYSIS (UA)
SHAN KESHRISHAN KESHRI
Clinical Sessions 2010Clinical Sessions 2010
MACROSCOPIC ANALYSISMACROSCOPIC ANALYSIS
DIPSTICK ANALYSISDIPSTICK ANALYSIS
THANKYOU FOR LISTENINGTHANKYOU FOR LISTENING
 http://www.emedicinehealth.com/urinalysis/paghttp://www.emedicinehealth.com/urinalysis/pag
e4_em.htme4_em.htm
 ColourColour change of dipstick?change of dipstick?
 http://en.wikipedia.org/wiki/Urinalysis#Medical_http://en.wikipedia.org/wiki/Urinalysis#Medical_
urinalysisurinalysis
 http://library.med.utah.edu/WebPath/TUTORIALhttp://library.med.utah.edu/WebPath/TUTORIAL
/URINE/URINE.html/URINE/URINE.html
 http://www.emedicinehealth.com/urinalysis/page3_em.htmhttp://www.emedicinehealth.com/urinalysis/page3_em.htm
 http://www.youtube.com/watch?v=_U1_TviVulshttp://www.youtube.com/watch?v=_U1_TviVuls really goodreally good vidvid
 http://www.youtube.com/watch?v=8h3GWjeT2eo&feature=relatedhttp://www.youtube.com/watch?v=8h3GWjeT2eo&feature=related
 http://www.patient.co.uk/doctor/Urinehttp://www.patient.co.uk/doctor/Urine--DipstickDipstick--Analysis.htmAnalysis.htm
 http://archive.student.bmj.com/issues/09/02/education/68.phphttp://archive.student.bmj.com/issues/09/02/education/68.php
 http://www.ucdmc.ucdavis.edu/cne/documents/competenhttp://www.ucdmc.ucdavis.edu/cne/documents/competen
cies/poct/Urine%20Dipstick.pdfcies/poct/Urine%20Dipstick.pdf
 OdourOdour, blood etc, blood etc
Bhavin Doshi
This presentation aims to present students with 
an overview of cannulation, the knowledge and 
skills required to undertake the procedure 
safely and competently, how to recognise, 
prevent and manage associated complications.
Peripheral cannulation provides access for the purpose of IV hydration 
or feeding and the administration of medications.
A Cannula is a flexible tube, usually 
containing a needle (stylet), which can be 
inserted into a body cavity, duct, or vessel in 
order to drain fluid or administer a 
substance such as medications.
A Catheter is a flexible tube that is inserted 
into a body cavity in order to withdraw or 
introduce fluids.
Peripheral cannulation is a common 
procedure with more than 24 million 
cannulae of all designs sold in the U.K.
Palpation of the vein should be performed before every cannulation to 
determine veins from arteries (arteries pulsate and veins do not), and also to 
locate valves.
Palpation is achieved by placing one or two fingers over the vein and pressing 
lightly; then releasing the pressure to assess the vein’s elasticity and rebound 
filling.
The ideal vein is bouncy, refills when depressed, is straight and free of 
valves.
Must choose a suitable vein for the intended purpose; (rate of flow, type of 
infusion, duration of therapy, avoid joints since it will lead to mechanical 
phlebitis or tissuing of cannula. And also restricts the patient’s movement.
• Age of the patient – small and very fragile veins in young and elderly
• Nutritional status – friable veins in those who are malnourished, deep 
difficult veins in obese patients
• Medical history – E.g. Amputations, lymphoedema, cerebrovascular 
accident, mastectomy (the arm on the side of the unaffected breast should be 
used), some surgical procedures or the presence of a haemodialysis shunt
• Prescribed medications such as anticoagulants or long‐term corticosteroids, 
which make the veins more fragile and prone to bruising
• The physical condition of the patient, for example venous access is more 
difficult if the patient is dehydrated, in shock or hypothermic
• Skill of the practitioner
• Use a tourniquet – apply 7‐8 cm above the chosen site, must be tight enough 
to impede venous return but not affect atrial flow
• Opening and closing the fist along with gravity both improve vasodilation
• Gentle tapping or stroking may improve vasodilation – but can be painful
• Apply heat – such as warm pack, or soaking limb in a bowl of warm water
For prolonged courses of therapy, it is recommended, although not always practical, to 
start distally and cannulate at proximal points since sites can be maintained for longer
Cephalic vein – takes a large gauge cannula and provides a natural splint, but is at a joint
Basilic vein – awkward for cannulation due to location, but is quite large
Dorsal venous network – easily accessible, visualised and palpated – contraindicated in 
older patients due to loss of turgor, so veins are not stable
• Use “over the needle” type of cannula – where cannula is mounted on the 
needle – available in various gauges (16–24g), lengths (25‐45mm), 
compositions and designs. Also different materials have differing flow rates.
• Smallest gauge should be used to minimise damage to the vessel intima and 
ensure adequate blood flow around the cannula (reduce risk of phlebitis).
• Cannula comprises of different components
Some have wings to help fix it to the skin, 
others have ports on top to enable the 
administration of medications without 
interfering with a continuous infusion. Safety 
cannulae are liable to reduce the risk of 
needlestick injury (have a safety button).
• There should be adequate lighting and the room should be warm enough to 
encourage vasodilation
• Practitioner should be in a comfortable position (alter height of bed or chair)
• Wear properly fitting gloves to protect from contamination by blood spillage
• Anxiety in patient due to needle phobia or previous bad experience could present
• Provision of clear and comprehensive information should alleviate anxiety
• A careful explanation should be provided of the procedures and patient consent 
must be gained (Verbal consent is usually acceptable)
• Patient should be in a comfortable position. Placing arm on a pillow or rolled 
towel provides support and a firm, flat surface
Non‐pharmacological methods
• Relaxation
• Distraction – E.g. Coughing at time of insertion of needle
Pharmacological methods
• Local anaesthetics in the form of cream or gel or intradermal injection has 
been advocated to reduce pain, and anxiety in children and selected adults
• Local anaesthetic is also recommended if the cannula is larger than 18g, when 
a sensitive site is used or at the patient’s request.
• It is important to clean the skin properly – wash with soap and water to 
remove visible dirt (removes transient flora)
• Use anti septic solution ‐ E.g. Chlorhexidine (2%) or alcohol (70%) for 30‐60s
• Allow skin to dry – ensures disinfection and avoids stinging from needle
• Do not touch or repalpate the skin – avaoids recontamination
• Hair removal is not neccessary – but can be trimmed with scissors or clippers
• Stabilisation of the vein – apply traction with non‐dominant hand to the side of 
the insertion site or below it, using thumb and forefinger
• Stabilisation of vein should be maintained throughout the procedure until cannula 
is sited
• Needle enters skin with bevel side up, so sharpest side penetrates skin first
• Angle needle enters varies depending on type of device used and the depth of the 
vein in the subcutaneous tissue, from 10 to 45 degrees
• Once entry into the vein is achieved, angle is reduced to prevent puncturing 
posterior wall of the vein
• When blood appears into chamber, it is known as “flashback”, indicating initial 
entry into the vein is successful
• Followed by a “giving way” sensation felt by the practitioner – overcoming of the 
resistance of the vessel wall
• Flashback may stop is posterior wall is pierced, or may slow if gauge of cannula is 
small or patient is hypotensive
• Cannula should be advanced gently and smoothly into the vein. The one‐handed 
technique – the same hand that performs cannulation also withdraws the stylet 
and advances the cannula into the vein
• The one‐step technique – where the practitioner can slide the cannula off the 
stylet in one movement once the cannula has entered the vein
• The two‐handed technique – where the practitioner performs the cannulation 
with one hand but releases the skin traction to advance the cannula off the stylet, 
which can result in puncturing of the posterior wall of the vein
• If cannulation is unsuccessful the stylet should never be reintroduced as this 
could result in catheter fragmentation and embolism. The device should only be 
used once.
• Only two attempts should be made at cannulation before passing the patient 
onto a more experienced practitioner
Step 1: Use a BD Venflon and a cooked piece of penne pasta. Using a BD 
Venflon is essential because the depth of its plastic casing means that the 
pasta sits nicely at an accessible height for cannulation (other brands often 
have deeper casings). 
Step 2: Open the cannula, unfold its wings, and remove the plastic sheath 
that covers the needle. Insert the sheath through the pasta to stent it. The 
pasta simulates the skin, and the tapering end of the sheath creates a space 
to cannulate, simulating the vein
Step 3: Put the stented pasta into the cannula box ready for practice. In a 
real scenario remember to wear gloves, clean the overlying skin, and locate 
a sharps box before starting. Cannulation is easier if you first try to increase 
venous filling. It helps to use a tourniquet; to lower the arm below the level 
of the heart; to ask the patient to open and close their fist; and gently to tap 
above the vein
Step 4: Take a three point grip of the cannula, with your thumb on the white 
cap, index finger on the coloured cap, and middle finger on the wing. In a 
real scenario apply counter‐traction to the overlying skin with your other 
hand to help anchor the vein during insertion
Step 5: Approach at a 30° angle to go through the skin (the outer layer of 
pasta) then reduce to a 15° angle to advance the needle inside the vein (the 
space between sheath and pasta) until you see the first flashback (in a real 
scenario). The flashback provides visual indication of venous entry. The first 
flashback occurs as you enter the vein, and the second occurs as the needle 
is withdrawn and blood moves to fill this space. There are three main 
explanations for failed needle insertions—missing the vein; perforating the 
posterior wall of the vein; and hitting a valve within the vein
Step 6: Now change your grip, so the thumb and middle finger are on the 
white cap to withdraw the needle about 5 mm to produce the second 
flashback. Importantly the index finger provides counter‐traction on the 
wing
Step 7: With just the index finger remaining in place at the wing, advance the 
cannula along the vein. In a real scenario this is the time to release the 
tourniquet
Step 8: Fully withdraw the needle. Remove the white cap and use it to cap 
the cannula promptly. To prevent bleeding in a real scenario, occlude the 
vein with your other hand at the tip of the inserted cannula while you 
remove the needle until you cap the cannula.
Step 9: When finished practising, remove the cannula, return the needle to 
the cannula, and return this unit to its sheath for safe storage and further 
practice
• Flushing should be performed before and after each use of the cannula
• If not used, the cannula should be flushed every 24 hours with 0.9% sodium 
chloride, using a pulsated (push pause) flush to create turbulent flow and positive 
pressure
• Needleless injection caps are used to reduce significantly the incidence of 
catheter occlusions.
• Cannula can be secured using clean tape or a securement device, which have 
been shown to reduce the risk of dislodgement and other complications such as 
mechanical phlebitis.
• A transparent dressing or low‐linting gauze should be applied and then a 
bandage may be applied. Transparent dressings, particularly moisture‐permeable 
dressings, should not be bandaged as visibility and moisture permeablity are 
obscured
• Date and time of insertion
• The location of device
• Type and gauge size of device
• Signature of the practitioner inserting the device
• Any other information that the practitioner feels is neccessary to ensure 
continuity of care, such as problems with access and/or anxiety related to needles
• Assessment of the site should be documented using relevant tools (Visual Infusion 
Plebitis Score) – next slide
• It is recommended that peripheral devices should be re‐sited every 72‐96 hours, 
although some literature supports extending the dwell time up to 144 hours under 
certain circumstances (E.g. Infusion of non‐irritant medications or fluids).
• Removal of cannula should be conducted under aseptic conditions
• Site should be inspected to ensure bleeding has stopped and should be covered 
with a sterile dressing.
• Cannula intergrity should be checked to ensure that the complete device has 
been removed
• Date, time and reason for removal of the cannula should be DOCUMENTED
Complications need to be recognised and managed at the earliest possible stage, 
as they can result in pain, patient anxiety, haematoma, inflammation, 
infiltration or extravasation.
• Haematoma formation
• Inadvertent arterial puncture
• Neural puncture
If these occur, then they MUST BE DOCUMENTED and the patient must be 
informed of who and when to contact if they develop numbness or tingling in the 
limb
• Phlebitis and infiltration are most common complications – management 
depends on cause and also depends on extravated materials
1.Peripheral cannulation provides intravenous access for:
a) Hydration
b) Feeding
c) Medications
d) All of the above
2. Which of the following statements is correct?
a ) Arteries and veins pulsate
b) Arteries do not pulsate
c) Veins do not pulsate
d) Veins pulsate
3. Which of the following is not a form of phlebitis:
a) Chemical
b) Physical
c) Infectious
d) Mechanical
4. The ideal vein for cannulation should:
a) Have a number of valves
b) Refill when depressed
c) Be rigid
d) Be located over a joint
5.  How often should a cannula that is not in use be flushed?
a) Every hour
b) Twice a day
c) Every other day
d) Every 24 hours
6. The success of cannulation may be influenced by a patient’s
a) Age
b) Nutritional status
c) Physical condition
d) All of the above
7. What percentage of chlorhexidine solution should be used to clean the skin?
a) 2
b) 5
c) 10
Department of Health (2007) High Impact Intervention No 2 Peripheral Intravenous Cannula
Care Bundle. www.clean‐safe‐care.nhs.uk/toolfiles/16_SL_HII_2_v2.pdf (Last accessed 
March 2nd 2010.)
Dougherty L (1996) Intravenous cannulation. Nursing Standard. 11, 2, 47‐51
Dougherty L (2008) Peripheral cannulation. Nursing Standard. 22, 52, 49‐56
Dougherty L, Lamb J (Eds) Intravenous Therapy in Nursing Practice. Second edition. 
Blackwell Publishing Oxford, 167‐196; 225‐270.
Infusion Nurses society (2006) Infusion Nursing standards of practice. INS, Norwood MA
Lavery I, Ingram P (2005) Venepuncture: best practice. Nursing Standard. 19, 49, 55‐56
Perucca R (2001) Obtaining vascular access. In Hankins J, Lonsway RAW, Hedrick C, Perdue 
MB (Eds) Infusion Therapy in Clinical Practice. Second edition. WB Saunders, Philadelphia 
PA, 375‐388
Royal College of Nursing (2005) RCN Standards for infusion Therapy. RCN, London
Springhouse (2002) IV Therapy Made Incredibly Easy. Second edition. Lippincott Williams & 
Wilkins, Philadelphia PA.
http://archive.student.bmj.com/issues/08/06/education/244.php (Last accessed on March 
6th 2010)
Bhavin Doshi
Direct administration of fluids into the vein of choice
SC (subcutaneous) or IM (intramuscular) injections  are limited to 3 mL since 
larger quantities lead to local problems
Only limit on IV is the total body fluid content, since total fluid intake should be 
35‐50 mL / kg body weight / day is acceptable (in 100kg man – 3.5 – 5L per day!!)
IVs are given when we need to give a lot of fluid, or if we need to dilute a 
medication a lot to reduce irritation
Usually given over longer periods of time (15 minutes to several hours) in 
contrast to SC and IM which give entire dose instantly
IV administration allows fastest method of administration (bioavailability / 
bioequivalence is high) because it goes directly into the blood, so may be used for 
rapid onset of medication
IVs are usually administered by 
bags of fluid that come 
premixed. The standard sizes 
range from 50 mL to 1000 mL.
The bag is hung from an IV pole, 
and IV tubing is attached to the 
bottom of the bag.
The tubing has several 
important parts:
a) Drip chamber
b) Roller clamp
c) Side clamp
d) Injection port
• If it is too full, we cannot see the drops, so cannot count them
• If it is not full enough, then this will allow air to get into the IV tubing and 
therefore into the patient’s circulatory system, which can be very dangerous, 
blocking a blood vessel (venous air embolism – VAE),or stopping the heart
• Located just below the bag
• Used to visualise the fluid dripping into 
the tubing from the bag
• This is where we measure the speed of 
a manual IV setup – we look at the 
chamber and count the number of drops 
per minute
• The drip chamber should always be 
about half full.
• This is what we use to control the rate at which the 
IV fluid infuses
• If we roll it one way, it squeezes the tubing more 
tightly, making it more narrow and therefore slowing 
the fluid flow through it
• If we roll it the other way, it loosens its pinching of 
the IV tubing, making the tubing less narrow, 
increasing the fluid flow through it
• All roller clamps on a set of IV tubing should be 
closed before we attach a bag of IV fluid the top of 
the tubing, ensuring no air gets into the tubing
• Every medication is ordered at a specific infusion 
rate (or flow rate)
• This is used when we want to completely stop the 
IV from flowing, without having to adjust the roller 
clamp
• It is useful for momentary breaks in the flow, 
without having to reset the flow rate again by 
readjusting the roller clamp all over again
• It woks by completely pinching off the IV tubing
when we slide the tube through the narrowest part 
of the clamp
• This is the place where medicine or fluids 
other than those in the current IV bag can be 
injected so that they will infuse into the 
patient’s vein through the IV tubing
• Here we can see 2 ports, one in the bag and 
one below the drip chamber, there is also 
usually one where the needle goes into the 
patient’s vein
• The injection port on the IV bag is used if 
we want to mix some kind of medication 
with the fluid in the bag (need to be 
compatible)
• If we want to inject medication or a second 
kind of IV fluid that we’ve already attached, 
then we will use one of the ports that are 
located below the drip chamber
• IV infusion works because of GRAVITY – pushes fluid down through tubing into 
the vein
• The higher the bag is hung, the greater the gravitational pressure on the IV 
fluid to go downward through the tubing, if the bag is not high enough, there 
will not be enough pressure to force fluid into the vein
• All IV bags must be hung above the patient’s heart in order for there to be 
enough pressure for the fluid to infuse – usually 3 feet above an adult patient’s 
heart
• Change in the movement of the patient will result in changes in the infusion 
rate, so constant monitoring is required – usually every hour and after any major 
change in position
• Sometimes needle can be dislodged from the vein so that the fluid is infusing 
into the tissue – infiltration – eventually IV will stop due to a higher pressure in 
the tissue compared with the IV tube. Look for swelling, coolness and pain
Can attach a peripheral line (to limb) – these can only be used for a short period, 
usually 3 days due to risk of infection, so if it is required for longer then it is 
standard procedure to move the injection site to a new location every 3 days
A central line is an IV attached to a vein in the chest – usually through the chest 
wall, or neck veins, but it is also possible to insert the cannula into a peripheral 
vein and move the tip of the cannula slowly upward until it reaches a central vein
• IV medication can be given continuously, or intermittently
• A patient who requires continuous infusion has a constant IV setup
• A patient who only requires intermittent IVs have a cannula setup to them 
continuously, which is independent of the IV infusion equipment
• The cannula has an injection port attached to it’s end called an infusion port 
adapter (sometimes referred to as a heplock or saline lock/port)
• Cannula should be flushed since it can become blocked by clotted blood – can 
use 2mL saline or 2mL heparin (concentration of 100U/mL) every 6‐8 hours
FOR MORE INFORMATION ON CANNULAS, SEE LECTURE ON INTRAVENOUS 
CANNULATION
• If patient is receiving continuous IV fluids 
and/or medication and in addition must receive 
a second kind of intermittent infusion, or if a 
patients current IV infusion must be interrupted 
in order to administer a second IV medication or 
fluid that is more pressing, then we need to 
hang a secondary IV for the patient
• Secondary IV = IV Piggyback = IVPB = Second IV 
bag hung next to first and enters patient through 
first set of IV tubing through an injection port 
below the drip chamber
• Usually used for medications which have 
smaller volumes than the primary IV (50 – 250 
mL). Is also, usually given intermittently
• Since we want the secondary infusion to infuse 
faster, we hang it higher than the first bag
• Sometimes we want to give an injection by intravenous administration, but 
want to give a small volume all at once. This could be for a few reasons: could be 
larger than 3mL; It will be better absorbed; avoid the first pass effect.
•We can give the IV injection all at once by inserting a syringe into one of the 
injection ports and this is called an IV push or Bolus
•It can be given alongside a continuous infusion or can be given into a heplock
which has previously been setup
• If the volume of fluid we 
wish to infuse is relatively 
small (E.g. For an infant or 
small child, then we need to 
use a method where small 
volumes can be controlled.
•We use a volume‐controlled 
burette ( allows measurement 
of 120 mL in graduations of 
1mL
•Still has drip chamber, roller 
clamp (on top so we can hang 
an IV bag above it, to mix a 
single dose) and injection port
at the top
• Most medications are mixed with IV fluids by injecting them directly into a 
premixed IV fluid bag
• Some drug manufacturers also produce special IV bags which contain a 
medication vial port, which allows specially shaped vials of powdered 
medication to be attached directly to the top of a special IV fluid bag
• E.g. Powdered Vancomycin hydrochloride into 100 mL of 0.9% Sodium Chloride
• It is becoming more and more common to for many IV setups in hospitals to be 
implemented using machines which control the infusion rate on their own, only 
requiring the practitioner to enter infusion rate in mL/hr. There are 3 common 
kinds of electronic infusion devices:
1. Volumetric Pumps – force fluid into the vein under pressure and against 
resistance, but DO NOT depend upon gravity. Rates need to be monitored 
regularly. Some have an inbuilt alarm when rate is not being maintained. Also we 
need to monitor regularly for infiltration
2. Syringe pumps ‐ these are used for infusion of a very small amount of fluid 
over an extended period of time, but we need to control the speed that the 
plunger is depressed. This is difficult to conduct manually, therefore syringe 
pumps are very useful. Some medications cannot be diluted without losing 
their efficacy, so these kinds of medications may be given using a syringe pump
3. Patient controlled analgesia – allows patient to choose when they can take 
their IV medication, based on how they feel. The device includes a button 
which the patient can press whenever they feel in need of pain relief, which 
triggers the machine to dispense the pre‐programmed dose of medication, The 
machine is also pre‐programmed to “time‐out” so that the patient cannot over‐
dose. Some machines record the frequency with which the patient presses the 
button, so that the practitioner is able to monitor how often the patient is in 
pain
• There are many different types of IV fluids, and often these fluids are expressed 
using abbreviations when they are written into the drug order form.
• Any number that appear in an IV abbreviation indicate percentages. E.g. D5W is 
5% dextrose in water and D2.5NS is 2.5% dextrose in 0.9% salt in water
• Remember that percentages in IV fluids and other medications actually 
represent number of grams in 100mL of diluent, so D2.5NS is 2.5g dextrose per 
100mL normal saline, which is actually 2.5g dextrose and 0.9g salt per 100mL 
water
• Before fluid can be given via the IV route the infusion set must be primed. This 
involves running the fluid to be infused through the set, to prevent an air 
embolus. Asepsis should be maintained during the procedure to prevent any 
internal or exposed areas being contaminated
• There are various types of infusion sets available:
• Large‐bore sets which have large internal diameter (reduced drops per mL 
ratio) so that there can be fast flow rate
• Smaller‐bore sets offer larger drops per mL value so can be used to 
administer crystalloid and diluted drug infusions
• Both types of devices are gravity dependent and flow is controlled by 
means of the roller clamp
•Only recommended sets may be used with electronic volumetric infusion 
devices
•All sets have a trocar and a luer lock connector
•Packaging should be sterile, intact and within expiry date
• Fluid to be infused
• Administration set
• Clean gloves / apron
• Receptacle for any discarded fluid
• Drip stand
• Alcohol swab
• Air inlet if using glass or rigid containers)
• The correct patient should be identified , consent obtained and information and 
reassurance given
• The fluid to be infused should be checked against the prescription by two 
practitioners – check date of prescription, expiry date of fluid and directions
• Check infusion set contents for signs of contamination
• Wash hands, don clean gloves and apron
• Remove any packaging. Maintaining asepsis, snap the seal where the 
administration set trocar is to enter the bag (invert the bag). If possible, hang 
fluid on a drip stand
• Close any flow controllers on the administration set. Expose the trocar without 
touching and advance into the appropriate port
• Gently squeeze the drip 
chamber, allowing it to 
partly fill with fluid
• Partially release the flow 
controller to allow fluid to fill and 
move through the tubing. This 
may require removing the 
protective cap at the luer lock 
connector to allow air to be 
expelled
• Expel any air by allowing the fluid to run through the set into a receptacle
• Connect to patient’s intravascular device according to local policy and 
DOCUMENT the procedure
http://www.cwladis.com/math104/lecture6.php (Last accessed on March 7th
2010)
Higgins, D. (2004) Priming an IV infusion set. Nursing Times
Jamieson, E.M. (2002) Clinical Nursing Practices. Edinburgh: Churchill Livingstone
Medical Devices Agency (2003) Infusion System Device Bulletin. MDA Device 
Bulletin 2003: 02. London: MDA
Quinn, C. (2000) Infusion devices, functions and management. Nursing Standard; 
14: 26, 35‐41
RCN (2003) Standards for Infusion Therapy. London: RCN
CommonCommon DrugsDrugs usedused toto treattreat
commoncommon respiratorespiratoryry disdiseaeasesess
(needs further explanations!)(needs further explanations!)
SHAN KESHRISHAN KESHRI
CLINICAL SESSIONS 2010CLINICAL SESSIONS 2010
Page references relate to OXFORD HANDBOOK OF CLINICAL MEDICINE, 7th Ed.
PnemoniaPnemonia (p.152)(p.152)
 AntibioticsAntibiotics –– infection?infection?
 AnalgesicsAnalgesics –– ParacetamolParacetamol forfor pleuriticpleuritic chest painchest pain
 IV Fluids (shock/dehydration)IV Fluids (shock/dehydration)
 OxygenOxygen –– to maintain PaOto maintain PaO22
BronchioBronchio--ecstasisecstasis (p.158)(p.158)
 AntibioticsAntibiotics -- infectioninfection
 BronchodilatorsBronchodilators –– nebulisednebulised SalbutamolSalbutamol ((ββ --2 agonists)2 agonists)
 CorticosteroidsCorticosteroids –– PrednisolonePrednisolone (anti(anti--inflammatory ofinflammatory of
mucosa)mucosa)
 Drain SputumDrain Sputum –– remove obstructionremove obstruction
ABCDABCD
Chronic AsthmaChronic Asthma (p.166)(p.166)
 Check inhaler techniqueCheck inhaler technique
 STEP 1: short actingSTEP 1: short acting ββ--2 agonist :2 agonist : SalbutamolSalbutamol
(bronchodilator and smooth muscle relaxant)(bronchodilator and smooth muscle relaxant)
 STEP 2: steroid:STEP 2: steroid: Beclometasone/FluticasoneBeclometasone/Fluticasone
 STEP 3: long actingSTEP 3: long acting ββ--2 agonist :2 agonist : SalmeterolSalmeterol
 STEP 4: increase dosesSTEP 4: increase doses
 STEP 5: addSTEP 5: add PrednisolonePrednisolone corticosteroidcorticosteroid
Chronic AsthmaChronic Asthma
 CorticosteroidsCorticosteroids :: PrednisolonePrednisolone via spacervia spacer
 AminophyllinneAminophyllinne (met. to(met. to TheophyllinneTheophyllinne)) : bronchodilator: bronchodilator
 ββ --2 agonists2 agonists :: SalbutamolSalbutamol inhalerinhaler
 AnticholinergicsAnticholinergics (prevent(prevent bronchoconstrictionbronchoconstriction)) :: IpratropiumIpratropium,,
TiotropiumTiotropium
CASACASA
Acute Severe AsthmaAcute Severe Asthma (p.794)(p.794)
 CorticosteroidCorticosteroid :: PrednisolonePrednisolone or Hydrocortisoneor Hydrocortisone
 AminophyllineAminophylline
 ββ--2 agonist2 agonist:: SalbutamolSalbutamol nebulisednebulised with oxygenwith oxygen
 AnticholinergicAnticholinergic:: IpratropiumIpratropium
CASACASA
COPD (stable)COPD (stable) (p.169)(p.169)
 AnticholinergicsAnticholinergics:: IpratropiumIpratropium
 ββ--22 agonist :agonist : SalbutamolSalbutamol,, SalmeterolSalmeterol (long lasting)(long lasting)
 Inhaled steroidInhaled steroid :: FluticasoneFluticasone
 SymbicortSymbicort (combination of anti(combination of anti--inflammatoryinflammatory
corticosteroid and long lastingcorticosteroid and long lasting ββ--22 agonistagonist
 Diuretics for edemaDiuretics for edema
 MucolyticsMucolytics
 Flu and pneumococcal vaccinations (prophylaxisFlu and pneumococcal vaccinations (prophylaxis))
COPD (acute)COPD (acute) (p.796)(p.796)
 OxygenOxygen
 NebulisedNebulised bronchodilator:bronchodilator: salbutamolsalbutamol,, ipratropiumipratropium
 AntibioticsAntibiotics: if infection, amoxicillin: if infection, amoxicillin
 Steroid : hydrocortisone,Steroid : hydrocortisone, prednisoloneprednisolone
 AminophyllinneAminophyllinne (decrease(decrease bronchobroncho--constriction)constriction)
OO--NASANASA
Pulmonary EmbolismPulmonary Embolism (p.174)(p.174)
 InvestigateInvestigate thrombophilliathrombophillia??
 Compression stockings (DVT) / EncourageCompression stockings (DVT) / Encourage
mobilisationmobilisation: improve venous return: improve venous return
 OralOral warfarinwarfarin (aim INR of 2(aim INR of 2--3)3) : prevent clots: prevent clots
 Massive: Morphine for pain andMassive: Morphine for pain and antiemeticantiemetic
 Anticoagulant LMW HeparinAnticoagulant LMW Heparin :: DalteparinDalteparin
II--COMACOMA
Pulmonary EdemaPulmonary Edema (p.787)(p.787)
 Nitrate (Nitrate (vasodilationvasodilation): spray sublingual,): spray sublingual,
IsosorbideIsosorbide dinitratedinitrate
 Oxygen (aid breathing)Oxygen (aid breathing)
 DiamorphineDiamorphine (chest pain relief)(chest pain relief)
 Diuretic:Diuretic: FurosemideFurosemide
NODDNODD
Arterial Blood Gas Sampling
ABG
Nathan Golban
Indications
To assess.
• Respiratory Status
Assess oxygenation and ventillation
• Acid Base Balance
• Phlebotomy. Used if venous route is
unavailable or inaccessible due to
trauma or burns. Usually a femoral
puncture, uncommon variation.
Contraindications
• Overlying infection or burn at insertion site.
• Absent collateral circulation.
• Arteriovenous shunt. Often radial or
brachial.
• Severe atherosclerosis
• Raynauds disease.
• Coagulopathy.
Sites
• Preferred radial or femoral arteries.
• Less common. Dorsalis pedis and
posterior tibial.
• Avoid. Branches without collateral supply.
Example is the brachial artery.
Complications
• Bleeding causing hematoma.
• Arterial occlusion causing thrombus or dissection.
• Infection causing arteritis or cellulitis.
• Embolization
• Last 3 uncommon.
Normal Values
• pH, 7.36 to 7.44. For acid base status of blood.
• pCO2, 38 to 44 mmHg. Reflects ventillation.
• pO2, 85 to 95 mmHg. Reflects oxygenation.
• HCO3, 21 to 27 meq per litre. Key blood buffer.
• Base excess, plus or minus 2 meq per litre
• ABG quiz.
http://www.vectors.cx/med/apps/abg.cgi
Pathophysiology
• Metabolic alkalosis
• Metabolic acidosis
• Respiratory alkalosis
• Respiratory acidosis
Initial Preparation
• Wash hands
• Gloves
• Protective eye wear
• Iodine swab. Povidone-iodine, betadine.
Followed by alcohol swab
• Arterial blood gas sampling kit
• 2 x 2 cm gauze
• Bag of ice. To store sample
Allens Test
• Indicates collateral circulation to hand.
• Radial artery on non dominant hand.
• Palpate radial artery.
• Simultaneouslys palpate ulnar artery, or as close
to that area as possible.
• Patient makes a fist. Palpate both arteries for10
seconds.
• Release ulnar artery and witness blood flow and
pinking of the hand via collateral radial artery
• Radial artery is now a candidate for testing.
Set Up
• Patient seated on stretcher
• Rolled up towel under wrist. That
hyperextends wrist, bringing artery closer
to surface.
• Clean area in a cicular motion with iodine.
Allow to dry.
• Wipe away iodine with alcohol. While
drying, open sampling kit.
Sampling Kit
• 3 pieces
1. Orange air ball or cube. Used to expel
excess air from the syringe.
2. Black cap for syringe, used for transport.
3. 3 cc, cubic centimetres heparinised
syringe. With needle attached.
Sampling Kit Use
• Pull back slightly on plunger, so once
needle is in artery, natural pulsations will
fill the syringe.
• Remove clear needle cap. Locate the
bevel. Bevel is a slanted opening on one
side of the needle tip. We want bevel
facing upward, so you can see it.
Syringe Use
• 45 degrees, sharper angle.
• Hold like a dart or pen.
• Feeling pulse under non syringe finger is the only
landmark for orientation.
• Before piercing skin, roll finger back slightly from artery,
so you dont stab yourself in the finger.
• Flash of blood into hub of needle. Artery has been
accessed.
• Blood will pulse into syringe. 1.5 to 2.0 cc required.
• Cover needle with gauze. Quickly remove needle.
After Care
• Physician applies pressure to gauze for 5
minutes. 10 minutes if patient is on
anticoaggulant therapy.
• Optional to ask patient to do this instead.
Blood Care
• Insert needle into orange air cube or ball. Want bevel
covered, dont want needle to go through cube.
• Push down on plunger to expell excess air. So it doesnt
affect results. Key point because we are measuring air
component levels in blood.
• Remove cube and needle as one.
• Attach black cap to syringe.
• Roll test tube between hands, to ensure blood
heparinisation.
• Place in iced bag. Send to lab.
• Needle and cube to sharps container.
Video
• http://www.youtube.com/watch?v=stxntv0
KkBE
Intro to Procedures:
The Arterial Blood Gas
(Source: Internet)
Information Obtained from an
ABG:
• Acid base status
• Oxygenation
– Dissolved O2 (pO2)
– Saturation of hemoglobin
• CO2 elimination
• Levels of carboxyhemoglobin and
methemoglobin
Indications:
• Assess the ventilatory status,
oxygenation and acid base status
• Assess the response to an intervention
Contraindications:
• Bleeding diathesis
• AV fistula
• Severe peripheral vascular disease,
absence of an arterial pulse
• Infection over site
Why an ABG instead of Pulse
oximetry?
• Pulse oximetry uses light absorption at
two wavelengths to determine
hemoglobin saturation.
• Pulse oximetry is non-invasive and
provides immediate and continuous
data.
Why an ABG instead of Pulse
oximetry?
• Pulse oximetry does not assess ventilation
(pCO2) or acid base status.
• Pulse oximetry becomes unreliable when
saturations fall below 70-80%.
• Technical sources of error (ambient or
fluorescent light, hypoperfusion, nail polish,
skin pigmentation)
• Pulse oximetry cannot interpret
methemoglobin or carboxyhemoglobin.
Which Artery to Choose?
• The radial artery is superficial, has
collaterals and is easily compressed. It
should almost always be the first
choice.
• Other arteries (femoral, dorsalis pedis,
brachial) can be used in emergencies.
Preparing to perform the
Procedure:
• Make sure you and the patient are
comfortable.
• Assess the patency of the radial and
ulnar arteries.
Collection Problems:
• Type of syringe
– Plastic vs. glass
• Use of heparin
• Air bubbles
• Specimen handling and transport
Type of Syringe
• Glass–
Impermeable to gases
– Expensive and impractical
• Plastic–
Somewhat permeable to gases
– Disposable and inexpensive
Heparin
• Liquid
– Dilutional effect if <2-3 ml of blood
collected
• Preloaded dry heparin powder
– Eliminates dilution problem
– Mixing becomes more important
– May alter sodium or potassium levels
The Kit
Air bubbles
• Gas equilibration between ambient air
(pO2 ~ 150, pCO2~0) and arterial
blood.
• pO2 will begin to rise, pCO2 will fall
• Effect is a function of duration of
exposure and surface area of air
bubble.
• Effect is amplified by pneumatic tube
transport.
Transport
• After specimen collected and air bubble
removed, gently mix and invert syringe.
• Because the wbcs are metabolically
active, they will consume oxygen.
• Plastic syringes are gas permeable.
• Key: Minimize time from sample
acquisition to analysis.
Transport
• Placing the AGB on ice may help
minimize changes, depending on the
type of syringe, pO2 and white blood
cell count.
• Its probably not as important if the
specimen is delivered immediately.
Performing the Procedure:
• Put on gloves
• Prepare the site
– Drape the bed
– Cleanse the radial area with a alcohol
• Position the wrist (hyper-extended,
using a rolled up towel if necessary)
• Palpate the arterial pulse and visualize
the course of the artery.
Performing the Procedure:
• If you are going to use local anesthetic,
infiltrate the skin with 2% xylocaine.
• Open the ABG kit
• Line the needle up with the artery, bevel
side up.
• Enter the artery and allow the syringe to
fill spontaneously.
Performing the Procedure:
• Withdraw the needle and hold pressure
on the site.
• Protect needle
• Remove any air bubbles
• Gently mix the specimen by rolling it
between your palms
• Place the specimen on ice and transport
to lab immediately.
PELVIC
EXAMINATION
SHAN KESHRI
CLINICAL SESSIONS
Anatomical bearings
INDICATIONS
 Vulva / Vaginal complaints
 Pain, discharge, abnormal bleeding, itching, mass
 Pregnancy suspected / proven
 Exposure to STI (HPV is a factor in nearly all cases of cervical cancer!)
SCREENING PRECANCEROUS
LESIONS OF CERVIX - Method
 Cervical Pap Smear
 WHAT : Take specimen of cells of cervix for microscope examination
 WHY : Identify cancerous changes (ep. cell abnormality) early in women at risk
SCREENING PRECANCEROUS
LESIONS OF CERVIX - Guidelines
START :
 3 years after onset of sexual activity
 21 yrs age
CONTINUE :
 Annually until age 30
 30yrs+, with 3 consecutive normal pap smears
 then only need testing once per 3 years unless present with a
risk factor e.g. STI, new sex partner
STOP :
 Total hysterectomy
 Low Risk women aged 65-70
PROCEDURE
 History
 Patient preparation (lithotomy position)
 External examination (vulva & glands)
 Internal examination (cervix & vaginal walls)
 Bi-Manual examination (vagina, cervix, uterus, adnexa (ovaries))
 Recto-Vaginal examination (surrounding structures)
HISTORY
 LMP : Last Menstrual Period date?
 History of abnormal pap smears?
 Birth control usage?
 Vulva and vaginal symptoms? (see ‘indications’)
 Num. sexual partners?, Sex. Orientation?
 STI concerns?
 Discomfort in previous pelvic exams?
 Post-menopausal?
 Pregnant?
 Hormone replacement therapy?
WASH HANDS & GLOVE UP!
EQUIPMENT
 Speculum (check screw is working)
 Water Soluble Lubricant
 Light Source
PATIENT PREPARATION
 Make sure patient has emptied bladder before
exam!
Change to gown (privacy) – sit on exam table, with drape
covering legs.
 Offer to have a chaperone in room whilst you
conduct examination!!!
 COMMUNICATE:
 Explain procedure to patient, alert them before you insert /
retract / move anything!
LITHOTOMY POSITION
 Lay down on table
 Guide feet into stirrups
 Ask ‘slide buttocks to end of table’
 Relax legs into abduction
 Ensure she is draped for minimal exposure!
EXTERNAL EXAMINATION
(vulva & glands)
How to Examine Bartholin Glands
 Separate labia with non dominant hand
 Place Index finger of dominant hand into introitus (entrance)
+- lubricant
How to Examine Bartholin Glands
Examine for what?
 Erythema
 Swelling
 Masses
 Rashes
 Tenderness, Discomfort, Irritation, Pain
 Lesions
 Trauma
Pathologies
Pathologies
•Often assoc. with pregnancy
INTERNAL (SPECULUM)
EXAMINATION
(cervix & vaginal walls)
& Cervical pap smear
Preparation
 Wear clean gloves
 Warm Speculum with warm water (check comfortable
temp by touching it to thigh)
 Apply water based lubricant to speculum
Insert Speculum
 Part labia minor & insert gently & slowly at
slight downward angle (care with urethra)
 Once past introitus (entrance of canal), insert into
vagina using downward pressure to depth 4-5cm.
 Speculum handle 2cm away from introitus
 Only then, Open speculum
Visualise Cervix
 Smooth & firm & shiny
Problem finding cervix?
 Find vaginal fold to guide
 Close speculum, back up 1-2 cm & reinsert back into vagina (using
downward pressure) in direction of vaginal folds
 Re-open slightly and search for cervix.
 May need to repeat many times!
Once found cervix:
 Open speculum further, and lock in place by turning
down the screw on thumb piece.
Take Specimen
Revise Pathology:
 Remember, Cervical cancer arises from the transitional
zone of cervix (most vulnerable)
 Pre-pubertal: junction lies in endocervix
 Post-pubertal: junction MOVES to exocervix, exposed to acid of vagina and
undergoes sq. metaplasia.
 Transitional zone is area between pre pubertal junction & post pubertal
junction.
Liquid Based Technique (endocervix)
 Rotate broom shaped brush
 Disconnect handle, and place brush in liquid based pap
container. (maintain Sterile Conditions)
Glass Slide Technique (endocervix)
 Rotate wooden spatula  Then, Rotate Endo-Brush in
internal cervical os
 Transfer specimen to slide
 Apply fixative to slide
 Cotton bud can be used instead of endo-brush in pregnant women
to minimise risk of bleeding and irritation.
ExoCervix Specimen
 Cotton tip swab: sample vaginal discharge and exocervix
for wet mount or cerv. culture. (e.g. AMIES media)
 Use swab to check pH (normal acidic = 4 / yellow pH paper)
 Blue (alkaline) : infection
DNA, Gonococal, Chlamydiae probes
 Position cotton tip swab in cervical os for 30s
 Place directly into medium provided & label
 If needed, a biopsy can be taken for histological
examination.
Remove Speculum
 Warn patient before
 Unscrew lock and gently retract
 Slowly close blades as you retract. Observe vaginal
walls.
 Blade should be completely closed when exiting introitus
After effects
 Warn there may be a small amount of bleeding
Risks
 No Medical Risks of pap smear
BIMANUAL VAGINAL
EXAMINATION
(vagina, cervix, uterus, adnexa (ovaries))
 Insert index and middle finger of dominant hand into
vagina, to palpate vagina, cervix and uterus & adnexa.
+- lubricant
 Use non dominant hand to press on abdomen to push
pelvic organs towards palpating dominant hand (which
elevates them)
Try to notice:
 Size
 Shape
 Tenderness
 Mobility
 Position
 Masses
 Vaginal walls
 with fingers
 Cervix
 with fingertips
 Uterus
 with fingertips and pressure on abdomen
 Ovaries (adnexa)
 e.g. fingers in right fornix and pressure externally on right iliac fossa
 mobile ovaries (2x3cm)
 Remove fingers
 Check glove for discharge
 Dispose
 Wash Hands
RECTO-VAGINAL
EXAMINATION
Indications
 Assess retro-verted uterus
 Screen for colorectal cancer (50yrs+)
 Evaluate pelvic pathology
 Insert index finger into vagina and middle finger into rectum. Apply
pressure to palpate structures
 Use non-dominant hand to press on abdomen to push pelvic organs
towards palpating dominant hand
Contra-Indications
 Consider examination under anesthesia for difficult patients
 Physical, mental disability
 Abnormal anatomy
 Physical immaturity
 Menstruation : Glass slide technique contraindicated
Liquid based still possible
Video Links
 Part 1:
 http://video.google.com/videoplay?docid=-
3683431334751191546&ei=Ch-YS-
i3Apa62wLzmdXZAg&q=pelvic+examination#
 Part 2:
 http://video.google.com/videoplay?docid=-
3683431334751191546#docid=-1686931554619562136
Further Reading
 Different types of speculum e.g. Sims?
 Details how to fixate the slides and perform wet mount
 Pathology: Uterine tumors
THANKS FOR LISTENING
•Obstetrics’ & Gynaecology
•Blood pressure investigations
•Swab analysis
By Arjun Bhusan Keshri & By Arjun Bhusan Keshri & 
Saanta ChatzialiSaanta Chatziali
What is Obstetrics?
Study and management of normal and abnormal pregnancies
Gynaecology?
Describes the study of diseases of the female genital tract 
and  reproductive  system  as  well  as  the  periods  of 
childbirth and postnatal life
Continuum between both subjects, therefore a Continuum between both subjects, therefore a 
definitive division is somewhat arbitrarydefinitive division is somewhat arbitrary
Common conditions seen in Obstetrics Common conditions seen in Obstetrics 
Common conditions seen in 
Gynaecology
When to do the breast examination?When to do the breast examination?
 First consultations of women over the age of 45
 Presence of secretions of milk at times not associated 
with pregnancy (galactorrhoea)
 Breast lumps/nodules felt on palpation
 Pain (chart)
 Discoloration or change in the quality of the skin: 
 Redness suggests infection/inflammation
 ‘Peau d'orange’ quality ‐ an "Orange Peel" like 
texture that's caused by an uncommon, 
aggressive inflammatory malignancy 
Breast Pain ChartBreast Pain Chart
 When pregnant, the amount of HCG hormone in When pregnant, the amount of HCG hormone in 
the body rises rapidly in the early days & weeksthe body rises rapidly in the early days & weeks
 A home pregnancy test can detect this in the A home pregnancy test can detect this in the 
urine or blood (the chemical markers)urine or blood (the chemical markers)
 However, the HCG hormone can only be detected However, the HCG hormone can only be detected 
accurately after implantation (there is also a false accurately after implantation (there is also a false 
result if the test is done too early)result if the test is done too early)
Common test examplesCommon test examples
 Error in application results if urine Error in application results if urine 
flow is lowflow is low
 Drugs interferenceDrugs interference
 Not 100% accurate (professionals Not 100% accurate (professionals 
estimate it to be 97% correct)estimate it to be 97% correct)
 Will not necessarily work if test is Will not necessarily work if test is 
taken too early taken too early 
 Wrap machine around Wrap machine around 
wrist or forearmwrist or forearm
 Push on/start buttonPush on/start button
 Read displayRead display
 Push off buttonPush off button
 Take machine offTake machine off
Evaluating Blood 
Pressure Readings 
Nasal SwabsNasal Swabs
 Detection of nasal infections, especially presence Detection of nasal infections, especially presence 
Staphylococcus Staphylococcus aureusaureus
 Insert swab into the anterior Insert swab into the anterior narenare (nostril)(nostril)
 Sweep upwards towards the top of the Sweep upwards towards the top of the narenare
 Repeat the procedure with the same swab in the Repeat the procedure with the same swab in the 
other other narenare
 Place  swab in culture mediumPlace  swab in culture medium
Throat SwabThroat Swab
 Similar technique to the nasal swab collectionSimilar technique to the nasal swab collection
 Rub the swab along the back of  the throat near the 
tonsils. Ask the patient to resist gagging and closing 
the mouth while the swab touches this area
 Used particularly in Used particularly in strep throatstrep throat
 nb do not used antiseptic mouthwash before the test
SkinSkin SwabsSwabs
 Rubbing (gently) across investigated area of skinRubbing (gently) across investigated area of skin
 Send to culture labSend to culture lab
You are now able to do the following:
1.1.Short  Overview  of  Obstetrics'  and  Gynaecology;  common Short  Overview  of  Obstetrics'  and  Gynaecology;  common 
conditions and risk factors conditions and risk factors 
2.2.Perform and interpret value of breast examination (quadrants, Perform and interpret value of breast examination (quadrants, 
common sites for lesions)common sites for lesions)
3.3.Perform  and  interpret  pregnancy  test  (urine  hormone Perform  and  interpret  pregnancy  test  (urine  hormone 
detection) detection) 
4.4.Perform and interpret blood pressure measurement  (manually Perform and interpret blood pressure measurement  (manually 
and electronic devices) and electronic devices) 
5.5.Perform and value of taking sterile Nose, Throat, and Skin SwabsPerform and value of taking sterile Nose, Throat, and Skin Swabs
Pooja Mithani
Indications:
 Where IV administration is not available.
 Drugs with specific actions on muscles.
 A longer half life is needed eg. Morphine for
anaesthesia
 Damage to the sciatic nerve. (Upper outer quadrant)
 Injection fibrosis - causes inability to flex muscle drug
is administered to.
 Thrombocytopenia (low platelets) and coagulopathy
(bleeding) can lead to hematomas.
 Local sepsis
 Arterial/IV injection
 Infection
 Check identity of patient and contents and expiry date of drugs
 Insert needle into syringe, and fill with the required amount of
drug. Tap syringe to bring any air bubbles to the top and push the
air out.
 Choose a suitable injection site and inspect for signs of
inflammation, swelling, infections or lesions
 5 main sites:
▪ Upper arm (deltoid) – vaccines
▪ Dorsogluteal (gluteus maximus)
▪ Ventrogluteal(gluteus medius)
▪ Vastus lateralis (quadriceps femoris) outer side of femur
▪ Rectus femoris (anterior quadriceps) – self administration or
infants
 Swab site with alcohol and let it dry (bactericidal and decreases
pain)
 Pull skin laterally and insert needle in one swift motion at 90°,
aspirate to avoid an intravenous placement, if blood is drawn in,
restart with new medication and slowly inject the drug.
 Remove needle and apply a pressure gauze and observe for
signs of an adverse reaction.
Moving the skin may distract from the intended needle
destination, therefore visualise and aim for the
underlying muscle about to receive the injection.
http://www.youtube.com/watch?v=nA8i9eYW0_M
Pooja Mithani
Indications
 When drug is desired to have a slow, sustained
absorption effect
 Local anaesthesia
 Administration of vaccines
and medicines such as
insulin and morphine
 Avoid using the same site repetitively which
can cause lumps or dents (lypodystrophies –
loss or degeneration of fat) from forming.
 Accidental IV, ID, IM injections
 Check identity of patient and contents and expiry date of
drugs
 Insert needle into syringe, and fill with the required amount
of drug. Tap syringe to bring any air bubbles to the top and
push the air out.
 Choose a suitable injection site and inspect for signs of
inflammation, swelling, infections or lesions
 4 main sites:
▪ Upper arm outer area
▪ Abdomen – above and below waist, except around navel
▪ Anterior thigh – midway of outer side
▪ Upper area of butt – behind hip bone
 When repeated injections are needed use a hidden
site to cover bruises – but the same area at the same
time each day to reduce changes in the action of the
insulin
 Swab site with alcohol and let it dry (bactericidal and
decreases pain)
 Gently pinch skin to elevate subcutaneous fat and
separate it from underlying muscle.
 Insert the needle at a 30° angle and inject the drug –
aspiration before injecting the drug is unnecessary as
can increase the risk of local hematoma formation for
heparin.
http://www.youtube.com/watch?v=bxdYGXKz1iA
Pooja Mithani
Contraindications
 Patient refusal – but many can be persuaded
 Allergy – rare
 DO NOT USE adrenaline containing LA on digits or
penis – vasoconstriction can lead to ischaemia and
necrosis.
 Anticoagulated patients have a tendency to bleed if a
vessel is punctured.
 Infection at intended site may make it more painful and
spread.
 Broken needles
 Acute systemic toxicity – CNS, CVS – when plasma
conc., exceeds toxic limit.
 LA block fast sodium channels in nerve axons
preventing propagation of nerve impulse
 Pain nerves are usually smaller and non myelinated
fibres so are blocked faster than larger myelinated fibres
(motor, proprioception, touch)
 Injected subcutaneously
 Onset of effect is 2 minutes, but duration
varies depending on the drug.
 LA solutions are alkaline pH 10/11
therefore are more painful
 A less painful approach would be ID
(instant anaesthesia)
 Avoid intra vascular injection, so aspirate
first.
ABDOMINAL EXAMINATIONABDOMINAL EXAMINATION
POSITIONINGPOSITIONING
 PatientsPatients handshands remainremain
on his/hers sideon his/hers side
 Legs,Legs, straightstraight
 HeadHead resting on pillowresting on pillow ––
if neck is flexed, ABDif neck is flexed, ABD
muscles will tense andmuscles will tense and
therefore harder totherefore harder to
palpate ABDpalpate ABD
 INSPECTIONINSPECTION
 AUSCULATIONAUSCULATION
 PALPATIONPALPATION
 PERCUSSIONPERCUSSION
INSPECTIONINSPECTION
INSPECTIONINSPECTION
 ShapeShape
 Skin AbnormalitiesSkin Abnormalities
 MassesMasses
 Scars (PreviousScars (Previous op'sop's --
laproscopylaproscopy))
 Signs of TraumaSigns of Trauma
 JaundiceJaundice
 CaputCaput MedusaeMedusae (portal H(portal H--T)T)
 AscitiesAscities (bulging flanks(bulging flanks)
 SpiderSpider NaviNavi--Pregnant womenPregnant women
 CushingsCushings (red(red--violet)violet)
Hands + MouthHands + Mouth
 ClubbingClubbing
 PalmerPalmer ErythmeaErythmea
 Mouth ulcerationMouth ulceration
 Breath (Breath (foeterfoeter ex oreex ore)
AUSCULTATIONAUSCULTATION
 Use stethoscope to listen toUse stethoscope to listen to
all areasall areas
 Detection of Bowel sounds
(Peristalsis/Silent?? = Ileus)
 If no bowel sounds heardIf no bowel sounds heard ––
continue tocontinue to auscultateauscultate up toup to
3mins in the different areas to3mins in the different areas to
determine the absence of boweldetermine the absence of bowel
soundssounds
 Auscultate for BRUITS!!! Swishing
(pathological)
sounds over the arteries (eg.
Abdominal Aorta)
PALPATION
ALWAYS ASK IF PAIN IS PRESENT
BEFORE PALPATING!!!
 Firstly:Firstly: Superficial palpationSuperficial palpation
 Secondly:Secondly: Deep where no pain isDeep where no pain is
present. (deep organs)present. (deep organs)
 Assessing Muscle Tone:
- Guarding = muscles contract when pressure is
applied
- Ridigity = inidicates peritoneal inflamation
- Rebound = Releasing of pressure causing
pain
MURPHY'S SIGN
 Indication:Indication:
- pain in U.R.Quadrant
 Determines:Determines:
- cholecystitis (inflam. of gall bladder)
- Courvoisier's law – palpable gall
bladder, yet painless
- cholangitis (inflam. Of bile ducts)
METHODMETHOD
 Ask patient to breathe out.
 Gently place your hand below the costal margin on the right sideGently place your hand below the costal margin on the right side at theat the
midmid--clavicularclavicular line (location of the gallbladder).line (location of the gallbladder).
 Instruct to breathe in.
 Normally, during inspiration, the abdominal contents are pushed
downward as the diaphragm moves down.
 If the patient stops breathing in (as the gallbladder comes in contact
with the examiner's fingers) the patient feels pain with a 'catch' in
breath.
 Test is positive.Test is positive.
BLUMBERG'S SIGNBLUMBERG'S SIGN
 Determines:Determines:
-- peritonitisperitonitis
-- appendicitisappendicitis
 ALWAYS START OPP. SIDE TOALWAYS START OPP. SIDE TO
WHERE THE PAIN IS !!!!WHERE THE PAIN IS !!!!
 ABD is compressed slowly andABD is compressed slowly and
then rapidly released.then rapidly released.
 Pain upon removal of pressurePain upon removal of pressure
rather than application ofrather than application of
pressure to the abdomenpressure to the abdomen
 Pain present = positive.Pain present = positive.
McBURNEY'SMcBURNEY'S POINTPOINT
 From ASIS (anteriorFrom ASIS (anterior
superior iliac spine) tosuperior iliac spine) to
the umbilicus.the umbilicus.
 Determines:
- location of appendix (varies)
- deep tenderness @ point = acute
appendicitis
NOTE:NOTE: McBURNEY'SMcBURNEY'S PUNCH SIGNPUNCH SIGN == Tenderness is presentedTenderness is presented
when gently tapping the area of the back overlying the kidney prwhen gently tapping the area of the back overlying the kidney producingoducing
pain in people with an infection around the kidney (pain in people with an infection around the kidney (perinephricperinephric abscess)abscess)
oror pyelonephritispyelonephritis..
Carnett'sCarnett's signsign
 Abd. pain remains unchanged
or increases when the muscles
of the abdominal wall are
tensed.
 Positive = Abd. wall is the
source of the pain (e.g. due to
rectus sheath hematoma).
 Negative = pain decreases when
the patient is asked to lift the
head; this points to an intraabdominal
cause of the pain
Fluid wave test / Iceberg Sign
 Test forTest for ascitesascites..
 Have patient push theirHave patient push their
hands down on the midlinehands down on the midline
of the abdomen.of the abdomen.
 Then you tap one flank,Then you tap one flank,
while feeling on the otherwhile feeling on the other
flank for the tap.flank for the tap.
 > 1 litre of fluid allows the> 1 litre of fluid allows the
tap to be felt on the othertap to be felt on the other
side.side.
SpleenSpleen
Only palpable if enlarged;Only palpable if enlarged; splenomegalysplenomegaly
–– indicated byindicated by Castell'sCastell's signsign (bulge of(bulge of
U.LQuadrantU.LQuadrant).).
Patient on
his/her
Right Side
& palpate
from
behind.
Liver
 PALPATE:PALPATE:
- from R.iliac fossa up towards and under the last
rib whilst the patient is breathing in deeply.
 ASSESSING:ASSESSING:
Regulatrities
Smoothness
Tenderness
 PERCUSSION:PERCUSSION:
- Outline of liver (norm: 8-12 cms)
- In Mid-Clavicular Line from 2nd
rib downwards
 Hollow ---> Dull ----> Hollow
HEPATO-JUGULAR REFLUX
 Pressing enlarged liver ---> Increases
Jugular Filling ----> Hepatic congestion
(R.Heart Failure)
Head of PancreasHead of Pancreas
 De Jardins Point:
- MCL
- 9th
Costal Cartilage
- Right Side
 Indication:
- Pancreatitis/Tumour @ head
THANK YOU FOR YOURTHANK YOU FOR YOUR
ATTENTIONATTENTION
NASOGASTRIC (NASOGASTRIC (RylesRyles) TUBES) TUBES
(NGT)(NGT)
SHAN KESHRISHAN KESHRI
CLINICAL SESSIONSCLINICAL SESSIONS
WHATWHAT
20 Fr LEVIN TYPE
Many holes
prevent
blocks!
Markers
INDICATIONSINDICATIONS
 ININ –– Fine Bore tube 12Fr (less irritating)Fine Bore tube 12Fr (less irritating)
 FeedingFeeding
 e.g. anorexia nervosa toe.g. anorexia nervosa to stabalisestabalise body weightbody weight
 e.g. esophageal cancer to maintain nutritional intakee.g. esophageal cancer to maintain nutritional intake
 Swallowing difficultySwallowing difficulty ((dysphagiadysphagia))
 Administer drugsAdminister drugs (inject into tube)(inject into tube)
 Oral substancesOral substances e.g. charcoale.g. charcoal (poison antidote,(poison antidote, antiflatulentantiflatulent, lower blood lipid), lower blood lipid)
INDICATIONSINDICATIONS
OUTOUT –– Large Bore tubeLarge Bore tube
 AspirationAspiration (suction) of stomach contents(suction) of stomach contents
 Gastric secretionsGastric secretions
 SwallowedSwallowed air / obstructionsair / obstructions / paralytic/ paralytic ileusileus
 ExtractExtract samples of gastric liquidsamples of gastric liquid for examinationfor examination
 Extract swallowedExtract swallowed toxin / poisontoxin / poison
 Patient who has undergonePatient who has undergone pneumonectomypneumonectomy
(risk of anesthesia related vomiting leading to aspiration of st(risk of anesthesia related vomiting leading to aspiration of stomach contents)omach contents)
INDICATIONSINDICATIONS
 IntraIntra--operativelyoperatively::
 Inflate / Deflate stomach, to give easier access to upperInflate / Deflate stomach, to give easier access to upper
abdomenabdomen
Continuous FeedingContinuous Feeding
 Gravity based systemGravity based system
 Feeding solution placed above level of stomachFeeding solution placed above level of stomach
Supervised feedingSupervised feeding
 Tube is connected toTube is connected to electronic pumpelectronic pump
 Controls and measures intake, & signals interruptions in feedingControls and measures intake, & signals interruptions in feeding..
Continuous DrainageContinuous Drainage
 Gravity Based System:Gravity Based System:
 Attach to collector bag. Placed below level of stomachAttach to collector bag. Placed below level of stomach
CONTRACONTRA--INDICATIONSINDICATIONS
 History of / currently has:History of / currently has:
 Gastric bypass surgeryGastric bypass surgery
 EsophagealEsophageal VaricesVarices
 Alcoholism, Liver DiseaseAlcoholism, Liver Disease
 Bleeding disordersBleeding disorders
 Fractured noseFractured nose
 Deviated septumDeviated septum
 Nasal / Sinus surgery / TraumaNasal / Sinus surgery / Trauma
 EtcEtc……
EQUIPMENTEQUIPMENT
 Cup ofCup of water with strawwater with straw
 patient sip during insertion of tubepatient sip during insertion of tube
 NasoNaso--gastric Tubegastric Tube (NGT)(NGT)
 LubricantLubricant
 pH / Litmus paperpH / Litmus paper
 Pen lightPen light
 Vomiting basinVomiting basin
 Measuring tapeMeasuring tape
 SurgicalSurgical TapeTape
 Mask and eye protectionMask and eye protection
 Non Sterile DrapeNon Sterile Drape
 Non sterile GlovesNon sterile Gloves
 60ml Syringe60ml Syringe
 Bottle of water for irrigationBottle of water for irrigation
NON STERILE TECHNIQUENON STERILE TECHNIQUE
 Classed as aClassed as a nonnon--sterile proceduresterile procedure because, as thebecause, as the
NGT passes through the nose, it will pick up bacteria onNGT passes through the nose, it will pick up bacteria on
the way down to the stomach anyway.the way down to the stomach anyway.
 Place non sterile drape across patients chest.Place non sterile drape across patients chest.
 Give patient the basin to holdGive patient the basin to hold
 In case of nausea / vomitingIn case of nausea / vomiting
ASSESSASSESS
 Has patient had :Has patient had :
 Nasal / Sinus Surgery?Nasal / Sinus Surgery?
 Fractured nose?Fractured nose?
 Deviated septum?Deviated septum?
 Nasal TraumaNasal Trauma
 Difficulty breathing through a particular nostrilDifficulty breathing through a particular nostril
 (ask them to blow nose)(ask them to blow nose)
 Check bothCheck both naresnares with pen lightwith pen light –– clear?clear?
 Inform patient to take sips of water through the straw,Inform patient to take sips of water through the straw,
during insertion of NGT, as this swallowing will help itduring insertion of NGT, as this swallowing will help it
pass more easily!pass more easily!
 Also explain it may cause discomfort.Also explain it may cause discomfort.
PROCEDUREPROCEDURE
Remember:Remember:
Safety & Communication!Safety & Communication!
PreparePrepare
 Wash HandsWash Hands
 Check identity of patient with request form / recordsCheck identity of patient with request form / records
 Name / DOBName / DOB
 Explain procedure to patientExplain procedure to patient
 Sitting positionSitting position
 Measure with the tube from theMeasure with the tube from the tip of the nosetip of the nose, to the, to the
tip of their earlobetip of their earlobe andand down to thedown to the xyphoidxyphoid processprocess..
 Tube is then marked at this level indicating how far theTube is then marked at this level indicating how far the
tube must be inserted in order to reach the stomach.tube must be inserted in order to reach the stomach.
 However, most tubes now have several standard depthHowever, most tubes now have several standard depth
markingsmarkings
 18" (46cm) / 22" (56cm) / 26" (66cm) / 30" (76cm) from distal18" (46cm) / 22" (56cm) / 26" (66cm) / 30" (76cm) from distal
end;end;
 Infant tubes have 1 cm depth markings.Infant tubes have 1 cm depth markings.
 Prepare surgical tape ready to fix tube in place after insertionPrepare surgical tape ready to fix tube in place after insertion
 Put Gloves onPut Gloves on..
 Lubricate first 2Lubricate first 2--4 inches of NGT4 inches of NGT
 Help it pass easilyHelp it pass easily
Ready to insertReady to insert……
Give patient water and remind to take sips duringGive patient water and remind to take sips during
insertion.insertion.
 Insert steadily, untilInsert steadily, until nasonaso--pharynx (resistance)pharynx (resistance)
 During insertion, the tube must point downDuring insertion, the tube must point down
 Then, atThen, at nasonaso--pharynx, twist the NGT 180 degreespharynx, twist the NGT 180 degrees
 MinimisesMinimises risk of the tube coiling at the back of the mouth!risk of the tube coiling at the back of the mouth!
EE
TT
Careful not to go down the wrong hole!
 When enteringWhen entering orooro--pharynx, greatest risk of gaggingpharynx, greatest risk of gagging (drink water!)(drink water!)
 Once in esophagus, goes down easy.Once in esophagus, goes down easy.
 When you reach the mark:When you reach the mark:
 Secure tube with the surgical tapeSecure tube with the surgical tape
 Attach Drainage / Feeding bagAttach Drainage / Feeding bag
 Document Procedure in patient recordsDocument Procedure in patient records
 IndicationIndication
 Size of tube usedSize of tube used
 Amount & nature of aspirateAmount & nature of aspirate
3 Ways to check correct position3 Ways to check correct position
1) Check pH of gastric contents1) Check pH of gastric contents
2) Chest X2) Chest X--Ray (CXR)Ray (CXR)
3) With Air bolus3) With Air bolus
1) Checking pH of gastric contents1) Checking pH of gastric contents
 Pinch tube before connecting syringe to end of NGTPinch tube before connecting syringe to end of NGT
 Connect 60ml SyringeConnect 60ml Syringe
 Withdraw 5Withdraw 5--10ml of gastric contents10ml of gastric contents
 Place a few drops of the contents on the pH / litmus paper.Place a few drops of the contents on the pH / litmus paper.
 pH paper preferred!pH paper preferred!
 pH <5.5 = Success!pH <5.5 = Success! (blue litmus strip turns red!)(blue litmus strip turns red!)
 Return contents of syringe to patient via NGT.Return contents of syringe to patient via NGT.
NB: pH PAPER
PREFERRED!
 Flush tube with water to prevent cloggingFlush tube with water to prevent clogging
 Fill syringe with water, hold above stomach level and allowFill syringe with water, hold above stomach level and allow
gravity to carry water to stomach.gravity to carry water to stomach.
 Flush tube with 30ml Air, to remove fluid from the line.Flush tube with 30ml Air, to remove fluid from the line.
2) Chest X2) Chest X--Ray (CXR)Ray (CXR)
•• Most ReliableMost Reliable
CXRCXR
 Measure length of tube outside of the body. (tip of noseMeasure length of tube outside of the body. (tip of nose
till end). Record.till end). Record.
 Send patient for CXR.Send patient for CXR.
 Upon return from CXR, measure tube ensuring it has notUpon return from CXR, measure tube ensuring it has not
moved.moved.
3) Using Air Bolus3) Using Air Bolus
•• Becoming an outBecoming an out--dated methoddated method
Less reliableLess reliable
 Take 60ml SyringeTake 60ml Syringe
 Pinch tube before connecting it to end of NGTPinch tube before connecting it to end of NGT
 Instill approx 30ml air to stomach.Instill approx 30ml air to stomach.
 At the same time, listen inAt the same time, listen in epiepi--gastric area withgastric area with
stethoscope forstethoscope for ‘‘whooshwhoosh’’ & bubbling.& bubbling.
 YES: Tip of NGT is in stomach = Success!YES: Tip of NGT is in stomach = Success!
MAINTAINENCEMAINTAINENCE
 Check positioning at least one a dayCheck positioning at least one a day
 Checking the markChecking the mark OROR
 Measure length of tube outside of bodyMeasure length of tube outside of body
 Mouth, Lip, Nose Care every 2 hrsMouth, Lip, Nose Care every 2 hrs
 Keep MoistKeep Moist
 TissuesTissues
 ToothbrushingToothbrushing
COMPLICATIONS & SIDE EFFECTSCOMPLICATIONS & SIDE EFFECTS
 Pain & DiscomfortPain & Discomfort
 Nose bleedsNose bleeds
 SinusitisSinusitis
 Sore throatSore throat
 VomitingVomiting
 Erosion of nose where tube is attachedErosion of nose where tube is attached
 Pulmonary aspirationPulmonary aspiration
 Perforation of stomachPerforation of stomach
 EsophagitisEsophagitis
 Tracheal/ Duodenal intubationTracheal/ Duodenal intubation
ALTERNATIVESALTERNATIVES
 Longer Term Feeding:Longer Term Feeding:
 PEG feedingPEG feeding ((percutaneouspercutaneous endoscopicendoscopic gastrostomygastrostomy))
 More possible complications (infection, peritonitis etc)More possible complications (infection, peritonitis etc)
FURTHER READINGFURTHER READING
 Differences in procedure for childrenDifferences in procedure for children
 NGT RemovalNGT Removal
LINKSLINKS
 http://http://www.youtube.com/watch?vwww.youtube.com/watch?v=WgfNa7dzSn0&feature==WgfNa7dzSn0&feature=player_embeddedplayer_embedded
 http://en.wikipedia.org/wiki/Nasogastric_intubationhttp://en.wikipedia.org/wiki/Nasogastric_intubation
 http://http://www.youtube.com/watch?vwww.youtube.com/watch?v=WgfNa7dzSn0&feature==WgfNa7dzSn0&feature=player_embeddedplayer_embedded
 Part 1:Part 1:
 http://http://www.youtube.com/watch?vwww.youtube.com/watch?v==TDXczuzHCeYTDXczuzHCeY
 Part 2:Part 2:
 http://www.youtube.com/watch?v=cTeEfULr0d0http://www.youtube.com/watch?v=cTeEfULr0d0
 http://http://www.youtube.com/watch?vwww.youtube.com/watch?v=6oxCda6FKUY&feature=related=6oxCda6FKUY&feature=related
First Aid
Devangna Bhatia
Equipment:
ABC’s:
D: Danger
R: Response
------------------
A: Airways
B: Breathing
C: Circulation
-------------------
D: Disability (acute problems) / defib if CPR
E: Exposure (to more danger)
What is First Aid and what are its
aims?
“Provision of initial care for an illness or injury.”
3 aims:
Preserve life
Prevent further harm - this covers both external factors, such as moving a patient
away from any cause of harm, and applying first aid techniques to prevent worsening
of the condition, such as applying pressure to stop a bleed becoming dangerous.
Promote recovery - first aid also involves trying to start the recovery process from
the illness or injury, and in some cases might involve completing a treatment, such
as in the case of applying a plaster to a small wound.
Before CPR – Primary Survey
1) Danger - Are you or the casualty in any danger? If you have not already done so,
make the situation safe and then assess the casualty.
2) Response - If the casualty appears unconscious check this by shouting:
‘Can you hear me?’, ‘Open your eyes’ and gently shaking their shoulders.
If there is no
response:
1) Shout for help.
If possible, leave the
casualty in the
position found and
open the airway.
2) If this is not
possible, turn the
casualty onto their
back and open the
airway.
If there is a response
AND no further danger:
1) leave the casualty in
the position found and
summon help if
needed.
2) Treat any condition
found and monitor
vital signs - level of
response, pulse and
breathing.
3) Continue
monitoring the
casualty either until
help arrives or he
recovers.
3) Airway - Open the airway by placing one hand on the casualty’s forehead
and gently tilting the head back, then lift the chin using 2 fingers only.
• This will move the casualty's tongue away from the back of the mouth.
4) Breathing:
• Look to see if the chest is rising and falling.
• Listen for breathing. no more than 10 seconds
• Feel for breath against your cheek.
1) If the casualty is breathing
normally , place them in the
recovery position.
2) 2)Check for other lifethreatening
conditions such as
severe bleeding and treat as
necessary.
1) If the casualty is not
breathing normally or if you
have any doubt whether
breathing is normal begin
CPR!!
Recovery Position
CPR – Cardiopulmonary Resuscitation
• Physical interventions to create artificial circulation by
chest compressions, and artificial respiration by the
rescuer exhaling into the patient (or using a device to
simulate this).
• Its main purpose is to maintain a flow of oxygenated
blood to the brain and the heart – both are vulnerable to
damage from hypoxia.
• Some brain cells start dying within less than 5 minutes
of hypoxia!
• CPR for adults: DEEP INHALATIONS AND EXHALATIONS!
30 compressions : 2 breaths for 2 minutes
rate of 100/min ventilation: 8 – 10 breaths/min
• CPR for children (1 year to puberty): SHALLOW BREATHS AND DON’T
EMPTY YOUR LUNGS COMPLETELY!
Start: 5 rescue breaths & 30 compressions
then continue with 30 compressions: 2 breaths
• CPR for babies (birth to 1 year): FILL YOUR CHEEKS WITH AIR AND
USE THIS!
Start: 5 rescue breaths & 30 compressions
then continue with 30 compressions: 2 breaths
• Agonal breathing : This is common in the first few minutes after a sudden
cardiac arrest. It usually takes the form of sudden irregular gasps for breath.
It should not be mistaken for normal breathing and if it is CPR should be
started.
CPR on adults
CPR on children: 1yr - puberty
CPR on infants:
ALS – Advanced Life Support
• Advanced life support, including intravenous drugs and defibrillation
(the administration of an electric shock to the heart) is usually
needed to restore a viable rhythm. This only works for certain
heart rhythms:
1) ventricular fibrillation (VF) (uncoordinated contraction of the cardiac muscle of the heart
ventricles, making them quiver rather than contract properly.)
2) pulse less ventricular tachycardia (fast heart rhythm, that originates in one of the
ventricles.)
• NOT useful in a 'flat line' asystolic patient, since the heart is already
depolarised. CPR and injections of epinephrine/atropine will help.
• CPR is generally continued, usually in the presence of advanced life
support, until the patient regains a heart beat (called "return of
spontaneous circulation" or "ROSC") or is declared dead.
Defibrillation
Consists of delivering a therapeutic dose of electrical
energy to the affected heart, using a defibrillator.
This depolarizes a critical mass of the heart muscle,
terminates the arrhythmia, and allows normal sinus
rhythm to be re-established by the sinoatrial node of
the heart.
CPR Videos
• http://www.youtube.com/watch?v=5r7haVfZXek
• http://www.youtube.com/watch?v=qSsHcdy4GnA
ALS Video:
• http://www.youtube.com/watch?v=zO3r50mIgr4
http://www.sja.org.uk/sja/first-aid-
advice.aspx
CENTRAL VENOUS
CATHETERISATION
Shilpa
Nelapathla
 Measurement of central venous pressure (CVP) 
( E.G. those with hypotension not responding to normal management, requiring 
infusion of inotropes)
 For long term administration of drugs for pain, 
infection, cancer or to supply nutrition.
 Venous access for IV fluids or antibiotics or a 
peripheral site is unavailable/unaccessible
 Haemodialysis   
 Patients undergoing thrombolytic or anticoagulative therapy
 Bleeding disorders
 Vasculitis
 Distorted local anatomy 
 Overlying skin infections( dermatitis), burns  
 Uncooperative  patient
• INFECTIOUS
Sepsis (also septic arthritis, osteomyelitis)
• VASCULAR 
Air embolism, blood clot, hematoma, arterial puncture 
• OTHERS
PNEUMOTHORAX, hemothorax, arrhythmias , nerve injury
 INTERNAL JUGULAR VEIN
 SUBCLAVIAN VEIN
 FEMORAL VEIN
Length of catheters
 15cm catheters for subclavian and internal jugular lines, and 
60cm catheters for femoral line
 Patient on a tilting bed, trolley or operating table
 Standard multiple lumen kit
 Guide wire
 Sterile gloves 
 Sterile gown
 Drapes 
 Disinfectant (Povidone‐iodine solution/ chlorhexidine)
 Suturing needle
 Scalpel
 Local Anaesthetic (lidocaine) 
 Sterile saline flush 
A= small syringe and  vial of  1% Lidocaine (L.A)
B= guide needle
C= IV syringe with catheter attached‐ D
E= Disinfectant sponge  
Guidewire: J‐shaped tip to reduce 
risk of vessel perforation
Dilator
Triple lumen       
catheter
 SELDINGER TECHNIQUE  (most common)
1) Use guide needle to locate the vein
2) Wire threaded through needle 
3) Remove needle
4) A dilator is passed over the guide wire
5) Dilator is removed and catheter is passed over wire and 
wire is removed
6) Catheter secured in place
Allows larger catheters to be placed in the vein after the passage of
appropriate dilators along the wire and a small incision in the skin at the point
of entry.
 Obtain informed consent and explain risks and benefits of 
procedure
 Optimal patient positioning and cooperation,  make sure patient is 
comfortable
 Take your time
 Sterile technique  
 Local anaesthetic should be used  
 Always have a hand on your wire
 Aspirate while advancing as you withdraw the needle slowly
 Withdraw  needle to the level of the skin before redirecting the
angle
 Don’t poke yourself with the needle
 The tip of the catheter can lie in either the superior or inferior vena 
cava (SVC or IVC) or into the right atrium (RA).
1. POSTIONING :
TRENDELENBURG POSITION
 Patient supine on  surface inclined 45 degrees, head at the lower
end and legs flexed over  upper end. 
( This distends the central veins and prevents air embolism)
 Head turned to opposite side of central venous line
 Stand at the head of the patient
 Ultrasound and landmarks can be 
used
 IJV is between the clavicular  and 
sternal heads of the 
sternocleidomastiod muscle
 Point of needle insertion is 
midway  between  sternal head of 
SCM and mastoid process behind 
ear   
 Disinfect area , apply L.A  and  fenestrated drape
 Place three fingers on carotid artery 
 Place needle about 45 degrees to the skin, lateral to the 
carotid artery
 Direct needle in sagittal plane angled towards feet 
 Vein should be 1‐1.5 cm deep, avoid deep probing in the 
neck 
 Seldinger technique used  
http://www.youtube.com/watch?v=QHiuYc22pfE
1.Disinfection, L.A and
sterile drape
2. Insert needle into
IJV and aspirate
3. Hold tip of needle with
one hand
4. Place wire through
needle and remove needle
5. Insert catheter over wire
then remove wire
6. Once catheter is in
place , secure and
apply dressing
POSITIONING
 Trendelenburg postion (10‐15 degrees) 
 Supine position, head and shoulders neutral  with arm slightly abducted
 Stand beside the patient at the side
PROCEDURE
 Disinfect area and apply local anaesthetic 
 Cover procedure area with fenestrated sterile drape
 Use seldinger technique 
LOCATION AND ACCESS TO VEIN
 Identify the midclavicular point and sternal notch
 Insert needle into the skin  1cm below and lateral to the midclavicular
point 
 Direction of needle should be parallel to skin 
 Advance posterior to the clavicle aiming for the sternal notch (Do not 
pass the needle further than the sternal head of the clavicle)
http://video.google.com/videoplay?docid=242132498694
8418582#
POSITIONING 
 Supine patient 
 Extend the patient’s leg and abduct slightly at the hip
PROCEDURE
 Disinfect area and apply local anaesthetic 
 Cover procedure area with fenestrated sterile drape
 Use seldinger technique 
LOCALISATION AND ACCESS TO VEIN
 Vein is medial to femoral artery
 Identify the pulsation of the femoral artery 1‐2 cm below the inguinal 
ligament.  
 Position needle at 45 degree angle and about 1cm medial to pulsation
 Needle  inserted at skin about 2 cm below inguinal ligament
 Aiming towards the umbilicus 
(In adults, the vein  normally found 2‐4cm from the skin. In small children 
reduce elevation on the needle to 10‐15° as the vein is more superficial)
http://www.4shared.com/file/61538831/b1027127/Placement_of_a_Fe
moral_Venous_.html
1) Aspirate blood from each port
2) Flush with saline / sterile water
3) Secure the catheter with sutures
4) Apply  sterile dressing 
5) Dispose of used gloves, needles, syringe etc
6) Wash hands 
7) Chest x‐ray for IJ and SC lines
LOCATION BENEFITS RISKS
INTERNAL JUGULAR
VEIN
•Bleeding can be seen 
and controlled
•Decreased risk of 
pneumothorax 
•Risk of Carotid artery 
puncture
•Pneumothorax
SUBCLAVIAN VEIN •Most comfortable for 
concious patients
•Increased risk of 
pneumothorax
•Should not be done on 
less than 2yrs 
•Vein is non‐
compressible
FEMORAL VEIN •Easy to locate 
•Less  bad 
complications
•No risk of 
pneumothorax
•Preffered in 
emergencies
•Highest risk of 
infection
•Risk of DVT
THANX FOR LISTENING!
Main Points
 What’s a suture?
 Why do I need to know how to do one?
 What instruments do I use for it?
Can I tie a knot?
What techniques shall I use?
What types of sutures and
materials do I know?
Definitions
 Suture: Is a medical device used to hold body tissues together after an injury or
surgery. To stitch together, cut or torn edges of tissue with suture material.
 Tensile Strength : The resistance of a material to a force tending to tear it apart,
measured as the maximum tension the material can withstand without tearing
Suture Characteristics
Absorbable
Sutures
Natural
Synthetic
Polymers
Collagen
Surgical gut,
plain
Surgical gut,
chromic
Dexon
(Polyglycolic
Acid Suture)
Vicryl
(Polyglactic
Acid Suture)
PDS
(Polydioxanone)
Maxon
(Polyglyconate)
Suture Characteristics II
 Absorbable Suture: A suture that
degrades and loses its tensile
strenght within 60 days under the
skin
 Natural Suture: Can be made of
collagen from mammal intestines or
from synthetic collagen (polymers)
 Synthetic:New technology in
surgical stitches
We use this sutures in patients who cannot return for suture removal,
or in internal body tissues
Absorbable Sutures
1. Catgut Suture: Tensile strength is
maintained for 7-10 days, absorption
complete within 60 days. Used for
ligating superficial blood vessels and
for epidermal use
2. Dexon and Vicryl: Tensile strength is
maintained for 14 days. Absorption
completed in 56-70 days. Used in
general soft tissues and vessel
ligations
3. PDS (Polydioxanone): Polyester
monofilament suture with tensile
strength maximal for 14 days.
Absorption completed within 6
months. Used for soft tissue
approximation in pediatric,
cardiovascular, gynecologic,
ophtalmic, plastic and digestive
situations.
Monofilament vs Multifilament
Mono is made of a single strand, more resistant
to microorganisms, less resistant to passage
through tissue, needs great care in handling and
tying because it crushes easily
Sutures Characteristics III
Non-Absorbable
Sutures
Natural
Synthetic
Polymers
Surgical
Silk
Surgical
Cotton
Surgical
Steel Nylon Polyester fiber
Novafil
(Polybutester)
Prolene
(Polypropylene)
Non-Absorbable Sutures
 Silk: Many surgeons consider silk suture the standard of performance. Tensile
strength decreases with moisture absorption and is lost by 1 year. The problem
is the acute inflammatory reaction triggered by this material.
Prolene: Monofilament suture, useful in
contaminated and infected wounds.
Widely used in plastic, cardiovascular,
orthopedic surgery. Ideal for use in
continuous suture closure.
Fig.A - Correction of blepharoptosis
Fig.B - Repair of a left indirect inguinal hernia
Suture Material – Needle Holders
Suture Specifications
Needles
• Curvature
• Straight needle
• Curved 2/8 of circle
• Curved 3/8 of circle
• Curved 4/8 of circle
• Curved 5/8 of circle
• Needle Tip
1. Taper
2. Conventional cutting needle
3. Reverse cutting needle
Traumatic needles: With holes or eyes which are supplied to the hospital,
separate from their suture thread. Suture must be threaded on site as is done
when sewing at home
Atraumatic needles: With sutures comprise an eyeless needle attached to
specific length suture thread
Suture Material - Needles
Fig.C – Atraumatic
Needle, Taper
Fig.D – 3/8 circle
needle, Cutting
Fig.D – Traumatic Needle,
Reverse Cutting
Suture Size
 Size O: Largest suture
 Size 2-O
 Size 3-O
• Skin: Foot or Sole
• Deep: Chest, Abdomen, Back, Scalp
 Size 4-O
• Skin: Scalp, Chest, Abdomen, Foot, Extremity
• Deep: Scalp, Extremity, Foot
 Size 5-O
• Skin: Scalp, Brow, Oral, Chest, Abdomen, Hand
• Deep: Brow, Nose, Lip, Face, Hand
 Size 6-O
• Skin: Ear, Lid, Brow, Nose, Lip, Face, Penis
 Size 7-O: Smallest Suture
• Skin: Eyelid, Lip, Face
Suture Removal Timing
Scalp: 6-8 days
Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
.Follow with papertape or steristrips
Ear: 10-14 days
Chest and abdomen: 8-10 days
Back: 12-14 days
Extremities: 12-14 days
Hand: 10-14 days
Foot and sole: 12-14 days
Penis: 8-10 days
Condition delaying Wound Healing: 14 to 21 days
Chronic Corticosteroid use and Diabetes Mellitus
Suture Technique
Pic.E - Suture Kit
http://www.softwarecasa.com/apprentice-doctor-how-to-stitch-up-wounds.html
The aim of all these techniques is
to approximate the wound edges
without gaps and without tension.
Staples are an expensive
alternative and glue may not be
widely available. Suturing is the
most versatile, least expensive and
most widely used technique.
The choice of sutures and needles
is determined by the location of the
lesion, the thickness of the skin in
that location, and the amount of
tension exerted on the wound.
List of Suture Techniques
:: Interrupted Suture
:: Continuous simple or Running Suture
:: Vertical mattress
:: Horizontal mattress
:: Subcuticular Suture
:: Purse string
:: Retention/tension
Simple Interrupted Suture
 The most commonly used and
versatile suture in cutaneous
surgery (i.e repair lacerations)
 This suture is placed by inserting
the needle perpendicular to the
epidermis, traversing the epidermis
and the full thickness of the dermis,
and exiting perpendicular to the
epidermis on the opposite side of
the wound
http://www.youtube.com/watch?v=PoO
RW7pQs2M
Continuous/Running Suture
 Is an uninterrupted series of simple interrupted sutures
 Poor cosmetic result but less time/consuming
 Is started by placing a simple
interrupted stitch, which is tied but
not cut. A series of simple sutures
are placed in succession without
tying or cutting the suture material
after each pass. The line of stitches
is completed by tying a knot after the
last pass at the end of the suture line
http://www.youtube.com/watch?v=H1FmNevH2QE&feature=related
Vertical Matress Suture
http://www.youtube.com/watch?v=qNcM6D9OK0s
Is a variation of the simple
interrupted suture.
It consists of a simple interrupted
stitch placed wide and deep into
the wound edge and a second
more superficial interrupted stitch
placed closer to the wound edge
and in the opposite direction.
Perfect apposition and great to
relieve tension from skin edges
Horizontal Matress Suture
 Is placed by entering the skin 5
mm to 1 cm from the wound edge.
 The suture is passed deep in the
dermis to the opposite side of the
suture line and exits the skin
equidistant from the wound edge.
 The stitch is passed deep to the
opposite side of the wound where
it exits the skin and the knot is tied
http://www.youtube.com/watch?v=Svcau54Svyg&feature=related
Subcuticular (Intradermal) Sutures
 Excellent cosmetic result
 It is placed by taking horizontal
bites through the papillary dermis
on alternating sides of the wound.
No suture marks are visible, and
the suture may be left in place for
several weeks
 Useful in wounds with strong skin
tension
http://www.youtube.com/watch?v=-osbgWMXcFE
Knot Tying
 Essentially there are 3 basic techniques:
1. Instrumental tie
- This is the most straightforward and the most commonly used technique
- You must cross your hands to produce a square knot
- Do not use instrument ties if the patient’s life depends on the security of the knot
Knot Tying II
2. One handed knot
Use the one handed technique to place deep
seated knots and when one limb of the suture is
immobilized by a needle or an instrument
Hand tying has the advantage of tactile sensations
lost when using instruments; if you place the first
throw of the knot twice, it will slide into place, but
will have enough friction to hold while the next
throw is placed
http://www.youtube.com/watch?v=b8JEuD0C3Pw&feature=related
Knot Tying III
3. Two handed knot
The two handed knot is the most
secure. Both limbs of the suture are
moved during its placement. A
surgeon’s knot is easily formed
using a two handed technique
With practice, the feel of knot tying will
begin to seem automatic. As with learning
any motor skill, we develop “muscle
memory”. Our brain teaches our hands how
to tie the knots, and eventually our hands
tie knots so well, we are no longer
consciously completing each step
Joao Marques de Oliveira
Rectal Examination
Nikos Lymberopoulos
Anatomy I
 The rectum is the curved lower, terminal
segment of large bowel.
 It is about 12 cms long and runs along
the concavity of the sacrum.
 Anterior to the lower 1/3 of the rectum lie
different structures in men and women
Anatomy II
 In men, anterior to the lower 1/3 of the
rectum lie the prostate, bladder base and
seminal vesicles.
 In women, anterior to the lower 1/3 of the
rectum lies the vagina. At the tip of the
examining finger it may be possible to
feel cervix and even a retroverted Uterus
 This is an intimate and sometimes
uncomfortable examination which is most often
done when disease (usually gastrointestinal or
genitourinary disease) is suspected or already
identified. It may also be done as part of a
screening examination when there is no
suspicion or expectation of disease but the
examination is performed as part of a thorough
screening process. It is important in all cases to
explain the reasons for the examination and to
get verbal consent.
Indications for R.E.
 Assessment of the prostate (particularly
symptoms of outflow obstruction).
 When there has been rectal bleeding (prior to
proctoscopy, sigmoidoscopy and colonoscopy).
 Constipation.
 Change of bowel habit.
 Problems with urinary or faecal continence.
 In exceptional circumstances to detect uterus
and cervix (when vaginal examination is not
possible).
Procedure
 The finger is then moved through 180°, feeling the walls
of the rectum. With the finger then rotated in the 12
o'clock position, helped usually by the examiner bending
knees in a half crouched position and pronating the
examining wrist, the anterior wall can be palpated.
Rotation facilitates further examination of the opposing
the walls of the rectum. In men, the prostate will be felt
anteriorly. In women, the cervix and a retroverted uterus
may be felt with the tip of the finger. It is important to feel
the walls of the rectum throughout the 360°. Small rectal
wall lesions may be missed if this is not done carefully.
Examination of the Prostate
Gland
 Normal size is 3.5 cms wide, protruding
about 1 cm into the lumen of the rectum.
 Consistency: it is normally rubbery and
firm with a smooth surface and a
palpable sulcus between right and left
lobes.
 There should not be any tenderness.
 There should be no nodularity.
External Inspection
 Skin disease.
 Skin tags
 Genital warts
 Anal fissures
 Anal fistula
 External haemorrhoids
 Rectal prolapse
 Skin discolouration with Crohn's disease
 External thrombosed piles
Internal Inspection
 Simple piles (but best examined at
proctoscopy)
 Rectal carcinoma
 Rectal polyps
 Tenderness
 Diseases of the prostate gland
 Malignant or inflammatory conditions of
the peritoneum (felt anteriorly)
Contraindications
 Imperforate Anus
 Unwilling patient
 Immunosuppressed patient
 Absence of anus following surgical
excision
 Stricture
 Moderate to severe anal pain
 Prolapsed thrombosed internal
hemorroids
OTOSCOPY &OTOSCOPY &
OPTHALMOSCOPOPTHALMOSCOPYY
SHAN KESHRISHAN KESHRI
CLINICAL SESSIONSCLINICAL SESSIONS
OTOSCOPYOTOSCOPY
http://medweb.cf.ac.uk/otoscopy/index.htm
ANATOMY OF EARANATOMY OF EAR
EXTERNAL
INNER
MIDDLE
Outer ear
& canal
until TM
Cochlea, SC
canals,vestibule
TM + air filled area
behind, including ossicles
ANATOMY OF EXTERNAL EARANATOMY OF EXTERNAL EAR
LAYERS OF TYMPANIC CAVITYLAYERS OF TYMPANIC CAVITY
MUCOSA
FIBROUS
LAYER
SKIN OF EXT. CANAL
FIBROUS LAYER:
Pars Tensa: circular
and radial fibres
Pars Flaccida: only
circular fibres
• Explain to patient what you are going to do.
– May be some discomfort, but should be no pain.
• Clean & Disinfect speculum, and wash hands between
patients
Safety & CommunicationSafety & Communication
• Clinical examination of the ear should begin with
a general examination of the external ear, and of
the lymph nodes of the head.
• Following this, we can use an otoscope to look
inside the ear.
To StartTo Start……
• In primary care we use otoscope aka auroscope
– Clean speculum & functioning batteries (BRIGHT light is important!!)
OTOSCOPE / AURISCOPEOTOSCOPE / AURISCOPE
Removable
Speculum
On / Off Switch
Battery Compartment
& Handle
Magnifying area
w/ light source
Speculum size should
be the
LARGEST THAT
CAN FIT WITHOUT
CAUSING PAIN
• Hold close to eyepiece for more control
– Pencil (or hammer grip)
– Right hand right ear, left hand left ear
• Pull pinna back and up to straighten ear canal
– To make speculum insertion easier
• Examine good ear first
QUADRANTSQUADRANTS
NORMAL TYMPANIC MEMBRANENORMAL TYMPANIC MEMBRANE
WHAT TO LOOK FORWHAT TO LOOK FOR
• External canal Wall
– Skin (normal, inflammed?)
– Debris?
• Malleus HANDLE (or lateral process)
• UMBO (malleus stria)
• CONE OF LIGHT (triangle shape, with apex at umbo))
• Inspect Pars Tensa, starting in Posterior-Superior quadrant,
clockwise
• Inspect Pars Flaccida
• Identify as many structures as you can
HUC
Ask YourselfAsk Yourself
• Can I see all the external auditory canal?
– stenosis, foreign body, edema, blood, debris
• Can I see the TM, or the handle of malleus, or both?
• Is the TM intact?
– retraction, perforation, blood vessels, clues about middle ear problems
• Is the TM correct colour and transparency?
– Gold/blue/dull = fluid/blood in middle ear
– White patches = tympanosclerosis (post-surgical?)
– Pearly grey = Normal
NORMAL TYMPANIC MEMBRANENORMAL TYMPANIC MEMBRANE
• Thin
• Semi-transparent
• Pearly grey
NORMAL TYMPANIC MEMBRANENORMAL TYMPANIC MEMBRANE
• Most otoscopes have a small air vent
connection that allows the doctor to puff air in
to the canal.
• Observing how much the eardrum moves with air
pressure assesses its mobility, which varies
depending on the pressure within the
middle ear.
INSUFFLATIONINSUFFLATION
CanCan’’t work out whatt work out what’’s what?s what?
• Look for the lateral process of malleus for orientation.
• Even when most other part have been destroyed, this is
usually still visible.
• Normal secretion of outer meatus
• Initially semi liquid and colourless, later oxidises to
yellow-brown harder substance which can block passage
of sound.
WAX / CERUMENWAX / CERUMEN
• Inflammation of middle ear (infection)
• Upper half:
– Prominent blood vessels, Bulging, malleus prominence
obscured (fluid)
• Lower half:
– Dull
ACUTE OTITIS MEDIAACUTE OTITIS MEDIA (w/ effusion)(w/ effusion)
NORM
• Inflammation of middle ear (infection)
• Bulging TM, with Purulent fluid behind a tense TM
• Risk of perforation – need to drain!
ACUTE OTITIS MEDIAACUTE OTITIS MEDIA (w/no definition)(w/no definition)
NORM
• Incomplete healing of OM
• Inflammatory process > Scar Tissue = Calcified plaques on TM
TYMPANOTYMPANO--SCLEROSISSCLEROSIS
NORM
• Causes include Trauma to head, Spontaneous perforation,
Loud sounds, Middle ear fluid build up, kissing ear (negative
pressure) etc
• Pressure related: circular
• Trauma related: cake shaped
CENTRAL PERFORATION OF TMCENTRAL PERFORATION OF TM
• Acute Otitis Media with effusion
• Secretory Otitis Media
• Fluid behind eardrum
• Resolution of Middle Ear Infection
• Serous Otitis Media
• Grommet / Tympanostomy tube
• Otitis Externa
OTHERS TO LOOK INTOOTHERS TO LOOK INTO
• Glue Ear (children)
• Myringotomy
• Retracted ear drum
• Cholesteatoma
• Grommets
• Tuning Fork tests – Rhines & Webers
• Tympanometry (jerger classification)
• Evoked Potentials
• Vestibulo-ocular relfex (VOR)
• Vestibulo-spinal reflec (VSR)
• Audiometry
• http://archive.student.bmj.com/back_issues/0795/7-otos.htm
• http://s818.photobucket.com/albums/zz101/bainiangudu168/video%20otoscope/?action=view&current=
002-2.flv
FURTHER READINGFURTHER READING
OPTHALMOSCOPYOPTHALMOSCOPY
Examination of eye
ANATOMY OF EYEANATOMY OF EYE
Sclera
Vascular Choroid
Photosensitive
Retina
OPTHALMOSCOPEOPTHALMOSCOPE
Lid
Depress and
rotate green
button to
turn on
Change
magnification
Look through
here
FACES
EXAMINER
FACES
PATIENTS
EYE
Magnification
number
OPTHALMOSCOPEOPTHALMOSCOPE
• Examine Fundus
– Interior surface of the eye, opposite the lens, includes
retina, optic disc, macula and fovea.
RETINARETINA
• Innermost of 3 layers
– Pars optica retina – photoreceptive
– Pars ceca retina – not photoreceptive
• Review 11 histological layers of retina
• Macula Lutea : flattened oval area in centre of retina,
slightly below optic disc.
– In centre: Avascular fovea centralis : point of sharpest visual
acuity; only cones, each with own nerve supply
RETINA: VASC SUPPLYRETINA: VASC SUPPLY
• Inner layers
– Central retinal arteries (br. of opthalmic)
• Occlusion > retinal infarction
• Outer layers
– No capillaries
– Nourished by diffusion from vascular choroid layer, which is
supplied by retinal arteries
• Retinal Arteries:
– BRIGHT red, BRIGHT relfex, NO PULSE, Paler with age,
• Retinal Veins:
– DARK red, NARROW reflex, SPONTANEOUS PULSE, 1.5x
THICKER
RETINA: NERVE SUPPLYRETINA: NERVE SUPPLY
• No Sensory supply
• Disorders of retina are painless!!
METHODMETHOD
• Slightly Dark room (dilated pupils – can apply eye drops to help)
• Ask patient to keep looking straight ahead and focus into
distance
• Check ophthalmoscope works and lid is open by shining onto
your hand
• Hold ophthalmoscope touching your eye, 30cm from
patient. Put spare hand on patients head
• From lateral side (holding ophthalmoscope in right hand for
right eye), look into the patients eye, through the pupil
• Observe red reflex
– reddish-orange reflection from the eye's retina
– No? – cataract, retinoblastoma??
• Move closer to eyes, focusing better using the focusing
dial
• Identify the optic disc (white circle / origin of all the blood
vessels) and see the fundus.
• Notice:
– Colour size borders of optic disc
– Vessels (of all quadrants)
– Macula
• Slightly darkened pigmented area, 2 optic disc widths from the
optic disc
– Fovea
• Ask patient to looked directly into light, and you may see it
• Do this last
NORMAL FUNDUSNORMAL FUNDUS
• Completely transparent retina, with no intrinsic colour.
• Uniform bright red coloration from the choroid layer vessels
• Optic disc: sharply defined, yellow-orange
– Younger people : pale pink optic disc
• Central Vein lies lateral to artery, no crossing over
• Uniform diameter of vessels
• Normal spontaneous venous pulse
• NO arterial pulse
NORMAL FUNDUSNORMAL FUNDUS
AGE RELATED CHANGESAGE RELATED CHANGES
• Optic disc turns pale yellow (from pink)
• Fundus turns dull, and non reflective
• Drusen visible
– tiny yellow or white accumulations of extracellular material that build up in
Bruch's membrane
• Thick vascular walls > less elastic
• Meandering of venules
– Sclerotic changes can compress vessels
ABNORMAL CHANGESABNORMAL CHANGES
• Loss of transparency of retina
– edema? – white/yellow
• Much more reading needed.
FURTHER READINGFURTHER READING
• Direct & indirect ophthalmoscope
• Ophthalmic history taking
• Tests or visual acuity (sharpness) : Snellens letter chart 20/20 /
pictogram kids
• Ocular motility : 9 possible degrees of gaze
• Strabismus, paralysis of ocular muscles, gaze paresis
• Binocular alignment: cover test
• Eyelid and nasolacrimal duct examination
• Conjunctiva examination
• Cornea, and corneal sensitivity
• Examination of anterior chamber
• Lens examination : slit lamp, focused light
• Confrontational field testing
• Measure intraocular pressure
• Admin of eye drops, ointment, eye bandages
Urethral Catheterization
Diogo Forjaz
Clinical Sessions
Masaryk University
Urethral Catheterization
Is a routine medical procedure that facilitates direct
drainage of the urinary bladder.
Catheters may be inserted as:
 an in-and-out procedure for immediate drainage,
 left in with a self-retaining device for short-term
drainage (eg, during surgery)
 left indwelling for long-term drainage for patients with
chronic urinary retention.
INDICATIONS
DIAGNOSTIC THERAPY
DIAGNOSTIC PURPOSES:
• Determine the etiology of various genitourinary
condictions
• Collection of urine specimen for microbiology testing
• Monitoring of urine output
THERAPEUTIC PURPOSES:
• Acute urinary retention (eg, blood clots)
• Chronic urinary retention (eg, obstruction that causes
hydronephrosis and damage of kidney)
• Intermittent decompression for neurogenic bladder
• Hygienic care of bedridden patients
• Benign prostatic hyperplasia
BUT ALSO:
 On patients who are anesthesized or sedated for
surgery or other medical care
 On comatose patients
 On some incontinent patients
 Post orthopedic surgery that may limit a patient's
movement
 On patients who are unable due to paralysis or
physical injury to use either standard toilet facilities or
urinals.
 Sometimes before Furosemide administration
CONTRAINDICATIONS
ABSOLUTE
traumatic injury in the lower urinary tract
Signs that increase suspicion for injury are:
 hematuria
 perineal hematoma
 blood at the meatus
 High riding prostate
a rectal exam, genital exam and a retrograde
urethrogram should be performed to rule out
prior to placing a catheter into the bladder.
injection of a radiopaque dye (contrast agent) into
the urethral meatus in conjunction with x-ray
imaging of the pelvic area.
CONTRAINDICATIONS
RELATIVE
Urethral stricture
Recent bladder or urethral surgery
Combative or uncooperative pt.
EQUIPMENT
Sterile drapes and gloves
Antiseptic solution (povidone-iodine)
Cotton balls and forceps
Catheter – FOLEY
Sterile lubricant
Syringe with saline for balloon inflation
Drainage bag
Viscous Lidocaine 2%
Tape to secure the catheter to patient.
http://www.youtube.com/watch?v=o0DoftBJ
1ew&feature=player_embedded
http://www.youtube.com/watch?v=NLJ4vwa
SOCE&feature=related
The maximal recommended volume for urethral balloon
inflation can be found on the inflation valve
(usually, 10-30 mL).
Catheter Types
1) Straight tip; 2) Coude tip; 3) 3-way
catheter irrigation
1) Straight tip catheter – 2 lumens:
urinary drainage
Inflate the balloon at distant end of catheter
2) Coudé tip catheter – 2 lumens and final
semirigid curved end to facilitate in
prostatic enlargement pt.
3) 3 way catheter irrigation – addition lumen
for drainage for post surgery bladder and
prostatic patients, for hematuria and clots
prevention.
CATHETER MATERIALS
 Latex
Silicone
If the pt. is allergy/hypersensivity
Silver
prevent colonization of bacteria, use in
recurrent urinary infections pt.
CATHETER SIZES
UNIT IS FRENCH
1 F is equivalent to 0.33 mm
Adults: Foley (straight tip) catheter (16-18F)
Adult males with obstruction at the prostate Coudé
tip (18 F)
Adults with gross hematuria - Foley catheter
(20-24F) or 3-way irrigation catheter (20-30F)
Children - Foley; to determine size, divide
child's age by 2 and then add 8
Infants younger than 6 months - Feeding tube
(5F) with tape
COMPLICATIONS
 INFECTIONS
(Urethritis, Cystitis, Pyelonephritis, Transient
bacteremia)
 PARAPHIMOSIS
(caused by failure to reduce the foreskin after
catheterization)
 Urethral STRICTURES
 Urethral PERFORATION
 BLEEDING
LONG TERM COMPLICATIONS:
Bladder spasm – due to inflated balloon
Blood infections – sepsis
Bladder stones
Bladder cancer
THANK YOU FOR
YOUR ATTENTION
Gait, Arms, Legs and Spine Examination
by David Utulu
 A GALS screen is an examination used by doctors and 
other healthcare professionals to detect locomotors 
abnormalities and functional disability relating to 
gait, arms, legs and the spine
Locomotors Examination
 G gait
 A arms
 L legs
 S spine
 To describe a rapid screening examination of the 
musculoskeletal system ‐ termed the ‘GALS’ screen
 To overview how abnormal joints are assessed during 
the physical examination  
GALS Screen – Gait, Arms, Legs, Spine
 The GALS screen aims to find out the following:
 Are any of the joints abnormal?
 What is the nature of the joint abnormality?
 What is the extent (distribution) of the joint 
involvement?
 Are any other features of diagnostic importance 
present?
The key questions
 Have you any pain or stiffness in your muscles, joints 
or back?
 Can you dress yourself completely without any 
difficulty? (dressing involves all joints)
 Can you walk up and down stairs without any 
difficulty? (assesses muscle wasting)
Gait
 observe patient walking, turning and walking back
 look for:
 smoothness and symmetry of leg, pelvis and arm 
movements
 normal stride length
 ability to turn quickly
 NB: Parkinson an patients have poor arm swing 
and cannot turn quickly
Arms
 Ask patient to stand in the anatomical position
 Check normal girdle muscle bulk and symmetry
 Check that elbows are straight and in full extension
 Attempt to place both hands behind the head, then push elbows 
back (look for glen humeral joint disease)
 Examine hands palms down, with fingers straight 
 Observe normal suspiration and probation (check for 
musculoskeletal dysfunction)
 Observe normal grip (reduced grip  arthritis)
 Place tip of each finger on to the tip of the thumb to assess 
normal dexterity and precision grip
 Squeeze across 2nd to 5th metacarpal (metacarpal ‘squeeze’
test) ‐ discomfort suggests sinusitis
Legs
 Observe any knee or foot deformity 
 Assess flexion of hip and knee, whilst supporting the 
knee
 Passively internally rotate each hip, in flexion
 Examine each knee for presence of fluid using ‘bulge’
sign and ‘patella tap’ sign
 Squeeze across the metatarsals to detect any synovitis
 Inspect soles of the feet for rashes and/or callosities 
(common in rheumatoid arthritis)
Spine
 Check par spinal and shoulder girdle muscle bulk and symmetry
 Look at straightness of spine (look for scoliosis)
 Check levels of iliac crest (look for hip pathology)
 Look for abnormal glutei muscle bulk (look for hip pathology)
 Check for political swellings (behind the knee)
 Check Achilles tendons (look for ethsopathy)
 Press over mid‐point of each supraspinatus and squeeze 
skinfold over trapezius ‐ tenderness suggests fibromyalgia.
 Note normal spine curvatures when standing, then ask patient 
to bend forward and assess lumbar and hip flexion – a straight 
spine and loss of lumbar flexion suggests enclosing spondylitis
 Try to place ear on the shoulder each side ‐ tests lateral cervical 
flexion.
Joint Abnormality
Active Inflammation
 Detailed examination of abnormal joints:
 Inspection
 Swelling, redness, deformity
 palpation
 Warmth, crepitus, tenderness
 movement
 Active, passive, against resistance
 Function
 loss of function
Inflammation of joints
 Arthritis’ refers to definite inflammation of a joint(s) i.e. swelling, 
tenderness,
 warmth and loss of function of affected joints.
 ‘Arthralgia’ refers to pain within a joint(s) without demonstrable 
inflammation by physical examination. Commonly occurs with SLE 
complaining of pain.
 The main signs of active inflammation include: swelling, warmth, erythema, 
tenderness, and loss of function of the joint.

 Site of swelling
 Tissue involved
 Indicative of…
 articular soft tissue
 joint synovium or effusion
 inflammatory joint disease
Inflammation of joints
 periarticular soft tissue
 subcutaneous tissue
 inflammatory joint disease
 non‐articular synovial
 bursa/tendon sheath
 inflammation of structure
 bony areas
 articular ends of bone
 Osteoarthritis
 Enthesopathy: pathology or lesions of enthesis (the site where 
ligament or tendon inserts into bone) Examples include: plantar
fasciitis, Achilles tendonitis.
 Irreversible Joint Damage
Joint deformity
 malalignment of two articulating bones
 Crepitus
 audible and palpable sensation resulting from movement of one 
roughened surface on another 
 classic feature of osteoarthritis e.g. patellofemoral crepitus on 
flexing the knee
 Loss of joint range or abnormal movement

 Dislocation: articulating surfaces are displaced and no 
longer incontact
 Subluxation: partial dislocation 
 Valgus: lower limb deformity whereby distal part is 
directed away from the midline e.g. hallux valgus
Joint deformity
 Varus: lower limb deformity whereby distal part is directed towards the 
midline e.g. varus knee with medial compartment OA
 Theses may be consequence of inflammation, degenerative arthritis or 
trauma:
 Identified by
 Painful restriction of motion in absence of features of inflammation
 e.g. knee ‘locking’ due to meniscal tear or bone fragment
 Instability associated with abnormal movement or abnormal range of 
movement
 e.g. side‐to‐side movement of tibia on femur due to ruptured collateral 
knee ligaments

 A spinal abnormality such as ankylosing spondylitis is a loss of the lordosis of 
cervical spine and lumbar spine. This pushes the head forwards, and means 
that a patient with this condition will be unable to look up.
Distribution of Joint Involvement
 Determine number of joints involved:
 polyarthritis > 4 joints involved
 oligoarthritis 2‐4 joints involved
 monoarthritis single affected joint
 Note if involvement is symmetrical
 Note the size of the involved joints
 Is there axial involvement?

 Bilateral and symmetrical involvement of large and 
small joints is typical of rheumatoid arthritis
 Lower limb asymmetrical oligoarthritis and axial
involvement would be typical of reactive arthritis
 Exclusive inflammation of the distal interphalangeal
joints of the fingers is highly suggestive of psoriatic 
arthritis
 The distribution of the polyarthritis is helpful in the differential diagnosis:
 Disease
 Joints involved
 Joints spared
 Rheumatoid arthritis
 PIP, MCP, wrist, elbow, shoulder, cervical spine, hip, knee, ankle, tarsal, MTP
 DIP, thoracic spine
 lumbar spine
 Osteoarthritis
 1st CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, 1st MTP, toe 
IP
 MCP, wrist, elbow, shoulder, ankle, tarsal joints
 Polyarticular gout
 1st MTP, ankle, knee
 Axial
 Other Diagnostically Important Features
 Rheumatoid nodules: collection of normal cells including 
lymphocytes, and fibroblasts that surround a center of fibrinoid
necrosis
 Tophi: deposit of crystallised monosodium urate in people with 
longstanding hyperuricemia
 Psoriasis: the characteristic skin condition may be present on 
various areas of the skin – commonly the elbows. In Psoriasis, 
patients commonly have nail “pitting” and also onycholysis –
separation or loosening of part or all of a nail from its bed.
 Malar rash: red/purple scaly rash.
NEUROLOGICAL EXAMINATION
SHAN KESHRI
CLINICAL SESSIONS
HISTORY
 Presenting symptoms:
 Headache
 Weakness
 Visual disturbance
 Special senses (hearing, smell, taste etc)
 Dizziness
 Speech disturbance
 Dysphasia
 Fits, faints, involuntary movements
 Tremor
 Skin sensation disturbance (sensory loss)
HISTORY
 Cognitive State
 Mini Mental State Exam
 Past Medical history
 Meningitis, encephalitis, trauma, seizures
 Drug History
 Anticonvulsant, antipsychotic, antidepressant, drugs with SE
 Social & Family History
 Barthel Index Score
Wash hands
UPPER LIMB EXAMINATION
 General Inspection
 Posture, asymettery, abnormal movements (fasciculation's, tremor),
muscle wasting
UPPER LIMB EXAMINATION
 Tone:
 Ask patient to relax
 Passively flex and extend limb, & also pronate and supinate
 Look for SPASTICITY / RIDGIDITY
UPPER LIMB EXAMINATION
 Power:
 Resist movements as appropriate to grade power.
 Test each muscle group bilaterally.
 Shoulder:
 “Shrug shoulders, don’t let me push down”
 “Push arms out the side against me, try to pull them back in”
 Elbow:
 “Hold forearms up, and pull me towards you”
 Finger extension:
 “Hold your hand out, don’t let me push it down”
 “Now don’t let me push it up”
 Offer two fingers and ask patient to squeeze
 Ask to spread fingers and resist you pushing them back
 .
UPPER LIMB EXAMINATION
 Tendon Reflexes:
 Compare left and right
 Distract patient e.g ask them to clasp hands tight
 Assess reflex as NORMAL, ABSENT, BRISK, EXAGGERATED
 Biceps: C5, C6
 Triceps: C7
 Supinator: C6
Biceps Reflex (C5,6)
Triceps Reflex (C7)
Supinator Reflex (C6)
UPPER LIMB EXAMINATION
 Co-ordination:
 Finger Nose Test:
 “Touch my finger, and then your nose as fast as you can”
 Look for tremor or past pointing, or missing the targets
 Test for dysdiadokokinesis:
 (failure to perform rapidly alternating movements)
 Ask patient to repeatedly pronate and supinate hands together
 Test for pronator drift:
 Patients eyes closed, arms outstretched palm up.
 Tap down on palm and look for failure to maintain supination
 .
UPPER LIMB EXAMINATION
 Sensation:
 Light touch
 Cotton wool- check dermatomes
 Pin Prick
 Temperature
 Hot & cold probes
LOWER LIMB EXAMINATION
 General Inspection
 Posture, asymettery, abnormal movements (fasciculation's, tremor),
muscle wasting
 Deformities, Pes cavus (champagne bottle below)
LOWER LIMB EXAMINATION
 Tone:
 Ask patient to relax
 Passively flex and extend at knees and hips and ankles, & also
internally and externally rotate
 Hold one hand on knee and rotate it
 Hold hand on back of knee and raise it quickly
 Heel should lift slightly
 Test for clonus (involuntary contractions)
 Plantar flex foot, the quickly dorsiflex.
 .
LOWER LIMB EXAMINATION
 Power:
 Resist movements as appropriate to grade power.
 Test each muscle group bilaterally.
 Hip:
 “Keeping your leg straight, can you lift your leg off the bed –
don’t let me push it down”
 “Using your leg, push my hand into the bed”
 “With my hands on outer thighs, push legs out to sides”
 “With my hands on inner thighs, push legs together”
 Knee:
 “Bend knee and bring you heel to your bottom – don’t let me pull
it away”
 “Now kick out against me”
 Ankle:
 “Bend foot down, pushing my hand down”
 “Cock up your foot, point toes to ceiling, pushing my hand up”
LOWER LIMB EXAMINATION
 Tendon Reflexes:
 Compare left and right
 Distract patient e.g ask them to clasp hands tight, clench teeth
 Assess reflex as NORMAL, ABSENT, BRISK, EXAGGERATED
 Knee: L3,4
 Ankle: L5, S1
 Extensor Plantar : L5, S1, S2
 Stroke sole of foot
 Positive Babinski : Dorsiflexion of great toe (Fanning)
 Abnormal over rage of 6m (UMN Lesion)
 .
Patellar Knee Reflex (L3,4)
Ankle Reflex (L5, S1)
Extensor Plantar Reflex (L5, S1, S2)
LOWER LIMB EXAMINATION
 Co-ordination:
 Heel to Shin test
 Put heel to shin and run heel up and down
 Both sides
LOWER LIMB EXAMINATION
 Sensation:
 Light touch
 Cotton wool- check dermatomes
 Pin Prick
 Temperature
 Hot & cold probes
LOWER LIMB EXAMINATION
 Gait:
 Ask patient to walk a few metres, turn and walk back
 Note use of walking aids, symmetery, size of pace, arm swing
 Ask patient to walk heel to toe (tightrope style)
 This exxagerates instabilities
 Ask patient to walk on tiptoes (S1 lesion), then on heels (L4,5 lesion /
foot drop)
 ROMBERGS TEST:
 Ask patient to stand unaided, arms by sides, then close eyes.
 Sway/loss of balance is positive
 posterior column disease / sensory ataxia
CRANIAL NERVE
EXAMAINATION
CN I: Olfactory
 One nostril at a time
 Put non-irritating stimulus near nostril
 Peppermint, lavender, coffee
 Detection of smell is more important than
identification
CN II: Optic
 One eye at a time, Cover the other
 Visual Acuity
 Snellen Chart / pictogram
 Visual fields:
 Central
 Face to face
 Tell patient stare at your nose
 Wiggle finger left and right, up and down
 Ask patient as you move can they see it
 Compare your field with patients
 Peripheral
 Face to face
 Tell patient to cover one eye
 You cover same side eye
 http://www.youtube.com/watch?v=mtdBGOvj-No
CN II: Optic
CN III, IV, V
Nystagmus?
CN V
 Sensory
 Cotton bud – close eyes, ask patient say where is the touch felt
 Forehead (opthalmic), cheek (maxillary), chin (mandibular)
 Motor
 Open mouth against resistance
CN VII
 Raise eyebrows, smile, puff cheeks
 Muscles of facial expression!
CN VIII
 Eyes closed
 Rub fingers near ear
 Say which side!
 Webers, rhines test – tuning fork
CN IX
 Gag reflex
 Touch back of palate with spatula
 Wretch
CN X
 Say “ahhhhhh” with mouth open and look with
torch
 Palate and uvula rise
 Cough
 Gag reflex
CN XI
 Turn head against resistance
 Shrug shoulders against resistance
CN XII
 Tongue protrusion (deviates to side of lesion?)
FURTHER READING
• Mingazinni
• Barres reflex
• Speech & higher mental function – aphasia (Broca, wernickes)
• UMN signs
• LMN signs
• Pyramidal signs
• Lassegues sign (and reverse)
Chest DrainsChest Drains
DevangnaDevangna BhatiaBhatia
Anatomy reviewAnatomy review
How to remember the order 
at the hilum:
Right Lung:
Bronchiole
Artery
Vein
Left Lung:
Artery
Bronchiole
Vein
INDICATIONSINDICATIONS
 PneumothoraxPneumothorax
 Pleural effusion (accumulation of fluid in the pleuralPleural effusion (accumulation of fluid in the pleural
space):space):
 MalignantMalignant
 ComplicatedComplicated parapneumonicparapneumonic
 TraumaticTraumatic haemopneumothoraxhaemopneumothorax
 ChylothoraxChylothorax: a collection of lymphatic fluid in the pleural: a collection of lymphatic fluid in the pleural
spacespace
 EmpyemaEmpyema: a: a pyogenicpyogenic infection of the pleural spaceinfection of the pleural space
 HemothoraxHemothorax: accumulation of blood in the pleural space: accumulation of blood in the pleural space
 Hydrothorax: accumulation of serous fluid in the pleuralHydrothorax: accumulation of serous fluid in the pleural
spacespace
 PostoperativePostoperative——Prevention of hydrothorax afterPrevention of hydrothorax after
cardiothoracic surgerycardiothoracic surgery
PneumothoraxPneumothorax
Definition:Definition:
 presence of air within the pleural spacepresence of air within the pleural space
Classification:Classification:
 Spontaneous (not caused by trauma)Spontaneous (not caused by trauma)
 TraumaticTraumatic
 IatrogenicIatrogenic
Depending on the size:Depending on the size:
 SmallSmall
 LargeLarge
presence of a visible rim of <2 cm or >2cm 
between the lung margin and the chest wall
Spontaneous (not caused by trauma)Spontaneous (not caused by trauma)
 PrimaryPrimary (PSP)(PSP) -- occurring in persons without clinically oroccurring in persons without clinically or
radiologicallyradiologically apparent lung diseaseapparent lung disease
 DueDue subpleuralsubpleural bullaebullae
 Familial (genetics)Familial (genetics)
 Cigarette smoking increases the risk of PSPCigarette smoking increases the risk of PSP
Clinical Signs:Clinical Signs:
 90% of PSP occur while the patient is at90% of PSP occur while the patient is at restrest
 Main symptoms areMain symptoms are chest painchest pain oror dyspnoeadyspnoea either alone or ineither alone or in
combination. Chest pain is more prominent and can be alone incombination. Chest pain is more prominent and can be alone in
69%69%
 Symptoms usually resolve within 24 hours, even if theSymptoms usually resolve within 24 hours, even if the
pneumothoraxpneumothorax remains untreated and does not resolveremains untreated and does not resolve
Spontaneous (not caused by trauma)Spontaneous (not caused by trauma)
 Secondary (SSP)Secondary (SSP)-- in which lung disease is present andin which lung disease is present and
apparentapparent
 Diseases of the airways: COPD, cystic fibrosis, and statusDiseases of the airways: COPD, cystic fibrosis, and status
asthmaticusasthmaticus
 Interstitial lung diseases:Interstitial lung diseases: LangerhansLangerhans cellcell histiocytosishistiocytosis,,
sarcoidosissarcoidosis,, lymphangioleiomyomatosislymphangioleiomyomatosis, tuberous sclerosis,, tuberous sclerosis,
rheumatoid disease, idiopathic pulmonary fibrosis, and radiationrheumatoid disease, idiopathic pulmonary fibrosis, and radiation
fibrosisfibrosis
 Infectious diseases: Necrotizing gramInfectious diseases: Necrotizing gram--negative pneumonia,negative pneumonia,
anaerobic pneumonia, staphylococcal pneumonia, AIDS withanaerobic pneumonia, staphylococcal pneumonia, AIDS with PP
jirovecijiroveci pneumonia, andpneumonia, and Mycobacterium tuberculosisMycobacterium tuberculosis
 Malignancies: Sarcoma, lung cancerMalignancies: Sarcoma, lung cancer
 Pneumoconiosis:Pneumoconiosis: SilicoproteinosisSilicoproteinosis,, berylliosisberylliosis, and bauxite, and bauxite
pneumoconiosispneumoconiosis
Clinical Signs:Clinical Signs:
 Occurs duringOccurs during acute exacerbationacute exacerbation. Should be. Should be
suspected if the patient fails to respond to currentsuspected if the patient fails to respond to current
treatment.treatment.
 DyspnoeaDyspnoea is more prominent than PSPis more prominent than PSP
 Chest painChest pain is less common but more severe thanis less common but more severe than
in PSPin PSP
 Symptoms of SSP donSymptoms of SSP don’’t resolve spontaneouslyt resolve spontaneously
TraumaticTraumatic
 Direct communication of the pleural spaceDirect communication of the pleural space
with the atmospherewith the atmosphere  penetrating injurypenetrating injury
 Disruption of the proximalDisruption of the proximal
tracheobronchialtracheobronchial tree or visceral pleuratree or visceral pleura
blunt chest traumablunt chest trauma
PA chest film demonstrates a right upper lobe mass 
abutting the pleural surface with associated metallic 
bullet fragments.
PneumothoraxPneumothorax: Signs: Signs
 Maybe minimal in smallMaybe minimal in small pneumothoraxpneumothorax or in SSP.or in SSP.
 Decreased movement of the chest wallDecreased movement of the chest wall
 HyperresonantHyperresonant percussion note with diminished tactilepercussion note with diminished tactile
focalfocal fremitusfremitus (palpable vibration) and resonance(palpable vibration) and resonance
 Decreased or absent breath sounds on the affectedDecreased or absent breath sounds on the affected
side.side.
 HaemodynamicHaemodynamic instability (tachycardia, hypotension,instability (tachycardia, hypotension,
and cyanosis) suggests tensionand cyanosis) suggests tension pneumothoraxpneumothorax..
PneumothoraxPneumothorax: Radiology: Radiology
CT scan (which is very sensitive) should be obtainedCT scan (which is very sensitive) should be obtained
if aif a pneumothoraxpneumothorax is suspected in case of :is suspected in case of :
 CXR of patient in a supine position and does notCXR of patient in a supine position and does not
demonstrate ademonstrate a pneumothoraxpneumothorax
OROR
 It can not be differentiated fromIt can not be differentiated from bullousbullous diseasedisease
CONTRA-INDICATIONS
• Coagulopathy
• Small, stable pneumothorax (may spontaneously 
resolve)
• Empyema (collection of pus) caused by acid‐fast 
organisms
• Fluid accumulation in small cavities (loculated
fluid accum.)
COMPLICATIONSCOMPLICATIONS
Minor complications:Minor complications:
 subcutaneoussubcutaneous hematomahematoma oror seromaseroma
 anxietyanxiety
 shortness of breath (dyspnoea)shortness of breath (dyspnoea)
 cough (after removing large volume of fluid)cough (after removing large volume of fluid)
Others:Others:
 HaemorrhageHaemorrhage
 InfectionInfection
 ReRe--expansion pulmonary oedema.expansion pulmonary oedema.
 Chest tube cloggingChest tube clogging
 Injury to the liver, spleen or diaphragm is possible if the tubeInjury to the liver, spleen or diaphragm is possible if the tube isis
placed inferior to the pleural cavity.placed inferior to the pleural cavity.
 Injuries to the thoracic aorta and heartInjuries to the thoracic aorta and heart
EQUIPMENTEQUIPMENT
Drapes
An assistant
Sterile gloves
Suture kit
Dressing pack
Gauze pads
Scalpel
1% or 2% lidocaine
2/0 silk suture on curved needle
10‐ml syringe
21‐gauge (green) needles
27‐gauge (orange) needles
Cleaning agent (e.g., iodine or 
chlorhexidine)
Chest drain
Chest drain bag (for pleural effusion) or 
water‐tight bottle containing some normal 
saline or sterile water (for pneumothorax)
TECHNIQUETECHNIQUE –– in shortin short
 Is drain really necessary?Is drain really necessary?
 Consent patientConsent patient
 Decide what size drain is neededDecide what size drain is needed
 Review imagingReview imaging
 Make sure the tray has everything you needMake sure the tray has everything you need
 Sterile techniqueSterile technique
 Have an assistantHave an assistant
 Chest xChest x--ray after insertionray after insertion
TECHNIQUETECHNIQUE -- detaileddetailed
 Make sure it is the correct patient and them tell them what youMake sure it is the correct patient and them tell them what you are going to do.are going to do.
 Wash your hands and put drapes on.Wash your hands and put drapes on.
 Confirm the position of theConfirm the position of the pneumothoraxpneumothorax/effusion clinically and also with a/effusion clinically and also with a
chest xchest x--ray.ray.
 Sit the patient upright, legs over the side of bed, leaning overSit the patient upright, legs over the side of bed, leaning over a high table soa high table so
the arms are up, the back is straight, and you have access to ththe arms are up, the back is straight, and you have access to the affected sidee affected side
of the chest. In an unwell patient, you might have to perform thof the chest. In an unwell patient, you might have to perform this with theis with the
patient sitting at a 45patient sitting at a 45°° angle.angle.
 Prepare the underwater sealPrepare the underwater seal –– fill a bottle onefill a bottle one--third full with sterile water. Thethird full with sterile water. The
end of the tube should be 2end of the tube should be 2––3 cm into the water.3 cm into the water.
 Choose the chest drain; tailor it to the patient by looking at hChoose the chest drain; tailor it to the patient by looking at how much rib spaceow much rib space
is available. Some chest physicians prefer larger drains, particis available. Some chest physicians prefer larger drains, particularly for effusionsularly for effusions
andand empyemasempyemas –– as a guide, 24F is suitable for aas a guide, 24F is suitable for a pneumothoraxpneumothorax; use 28; use 28––32F32F
for effusions andfor effusions and empyemasempyemas..
 Put on your gloves and prepare your cart so that all of the itemPut on your gloves and prepare your cart so that all of the items are within easys are within easy
reach.reach.
 Clean the patient's skin withClean the patient's skin with chlorhexidinechlorhexidine or iodine and perform pleuralor iodine and perform pleural
aspiration in the midaspiration in the mid--axillaryaxillary line at the 4thline at the 4th––5th5th intercostalintercostal space; aim above thespace; aim above the
rib.rib.
 When pleural fluid has been located, insert more localWhen pleural fluid has been located, insert more local anestheticanesthetic: Be generous: Be generous
–– use up to 15 ml in the area around the aspiration site. Some pause up to 15 ml in the area around the aspiration site. Some patients mighttients might
find this uncomfortable, so you can give a small dose offind this uncomfortable, so you can give a small dose of diamorphinediamorphine IV with 10IV with 10
mgmg metoclopramidemetoclopramide IV.IV.
 Make a 1Make a 1––2 cm incision with the scalpel in line with the ribs, remaining2 cm incision with the scalpel in line with the ribs, remaining justjust
above the lower rib. When you are through the skin and into theabove the lower rib. When you are through the skin and into the subcutaneoussubcutaneous
fat, bluntfat, blunt--dissect down with forceps. Continue until you reach the pleura.dissect down with forceps. Continue until you reach the pleura. ThisThis
can be painful, so have remaining localcan be painful, so have remaining local anestheticanesthetic available and inject intoavailable and inject into
pleura if necessary.pleura if necessary.
 Take the introducer out of the chest drain, so only the tubing rTake the introducer out of the chest drain, so only the tubing remains. After youemains. After you
have blunthave blunt--dissected the pleura and fluid or air begins to escape, insert tdissected the pleura and fluid or air begins to escape, insert thehe
drain into the hole. It should enter the pleural cavity easily,drain into the hole. It should enter the pleural cavity easily, but keep a fingerbut keep a finger
over the end of the drain until it is connected to the bag or unover the end of the drain until it is connected to the bag or underwater seal.derwater seal.
 Place a 1Place a 1--mattress suture on either side of the drain and pull taut. Placemattress suture on either side of the drain and pull taut. Place anotheranother
suture in the middle of incision around the drain. Tie the two ssuture in the middle of incision around the drain. Tie the two side sutures, soide sutures, so
the skin is pulled tight, then secure around the drain by coilinthe skin is pulled tight, then secure around the drain by coiling around severalg around several
times. Leave the central suture free, to be tied when the draintimes. Leave the central suture free, to be tied when the drain is removed.is removed.
 Place pads of gauze around drain and secure with dressing. SecurPlace pads of gauze around drain and secure with dressing. Secure the proximale the proximal
part of the drain to the patient with tape.part of the drain to the patient with tape.
 Ensure that the drain is draining/bubbling freely. Get a postEnsure that the drain is draining/bubbling freely. Get a post--procedure chest xprocedure chest x--
ray to review the position.ray to review the position.
 http://http://www.youtube.com/watch?vwww.youtube.com/watch?v=tSXQ7GR35E4=tSXQ7GR35E4
 http://http://en.wikipedia.org/wiki/Seldinger_techniqueen.wikipedia.org/wiki/Seldinger_technique
SITE OFSITE OF
INSERTIONINSERTION
Pectoralis major
Superior Line to the horizontal level of the nipple
Latissimus dorsi
Semi‐recumbent ‐ “Safe triangle”
Triangle  bordered  by  the  anterior  border  of  the 
latissimus dorsi, the lateral border of the pectoralis
major muscle, a line superior to the horizontal level 
of the nipple, and an apex below the axilla
BE CAREFUL AS TO AVOID:BE CAREFUL AS TO AVOID:
 Internal mammary arteryInternal mammary artery
 IntraIntra--abdominal insertionabdominal insertion
 Damage to muscleDamage to muscle
 Damage to breast tissueDamage to breast tissue
 UnsightlyUnsightly scarringscarring
REMOVALREMOVAL
Explain the procedure to the patient
Remove dressing and stay sutures.
Cover the site of tube entry with sterile gauge.
While patient performs Valsalva manoeuvre, 
remove the drain with a swift action and cover 
the wound with the gauge. Place a dressing on 
the gauze.
Thank You!Thank You!
ECG {Electrocardiogram}
by
David Utulu
Introduction
The Heart
• The heart consists of four 
chambers
– The right atrium and right 
ventricle: responsible for 
delivery of deoxygenated 
blood to lungs
– The left atrium and left 
ventricle: responsible for 
delivery of oxygenated blood 
to the body
The Heart: Phases
 There are two phases of the cardiac cycle
 Systole: The ventricles are full of blood and begin to 
contract.  The mitral and tricucuspid valves close 
(between atria and ventricles).  Blood is ejected through 
the pulmonic and aortic valves.
 Diastole: Blood flows into the atria and through the open 
mitral and tricuspid valves into the ventricles.
ECG
The ECG records the electrical signal of the heart as the 
muscle cells depolarize (contract) and repolarize.
Normally, the SA Node generates the initial electrical 
impulse and begins the cascade of events that results in a 
heart beat.
Recall that cells resting have a negative charge with 
respect to exterior and depolarization consists of positive 
ions rushing into the cell
Cell Depolarization
• Flow of sodium ions into cell during activation
Depol Repol. Restoration of
ionic balance
ECG Leads• In 1908, Willem Einthoven
developed a system capable of 
recording these small signals 
and recorded the first ECG.
• The leads were based on the 
Einthoven triangle associated 
with the limb leads.
• Leads put heart in the middle 
of a triangle
ECG Leads
 The basic values
 The lead values
Also note that by KVL:
VI + VIII = VII
ECG: Electric Signal
• Assumptions
– Model cardiac source as a dipole producing an electric 
heart vector, p.
– Model body as an infinite, homogeneous volume 
conductor 
• The leads will pick up the projection of the electric heart 
vector, p, along the lead
Propagating Activation 
Wavefront
• When the cells are at rest, they have a negative 
transmembrane voltage – surrounding media is positive
• When the cells depolarize, they switch to a positive 
transmembrane voltage – surrounding media becomes 
negative
• This leads to a propagating electric vector (pointing from 
negative to positive)
Propagating Activation Wavefront
• When the activation does not align directly with the lead 
(or propagate directly toward and electrode), the signal is 
proportional to component of the activation direction 
along the lead direction.
ECG Signal
• Heart behaves as a syncytium: a 
propagating wave that once 
initiated continues to propagate 
uniformly into the region that is 
still at rest.
• The depolarization wavefront
defines a dividing line between 
activated and resting cells. 
• Elsewhere, the signal is zero
• Will propagate along conduction 
paths – sinus node – AV node –
bundle branches – Purkinjie
fibers
ECG Signal
• The excitation begins at the 
sinus (SA) node and spreads 
along the atrial walls
• The resultant electric vector is 
shown in yellow
• Cannot propagate across the 
boundary between atria and 
ventricle
• The projections on Leads I, II 
and III are all positive
Normal ECG Signal
• P – atrial
depolarization
• QRS complex –
ventricular 
depolarization
• T – ventricular 
repolarization
Augmented Leads
• Three additional limb leads are also used: aVR, aVL, and 
aVF
• These are unipolar leads
• Each lead uses the average of the average of the other 
two leads as reference
– VR = ΦR – (ΦL + ΦF)/2
Precordial Leads
• Measure potentials close to the heart, V1‐ V6
• Unipolar leads
ECG Information 
• The 12 leads allow 
tracing of electric vector 
in all three planes of 
interest
• Not all the leads are 
independent, but are 
recorded for redundant 
information
ECG Diagnosis
• The trajectory of the 
electric vector resulting 
from the propagating 
activation wavefront can be 
traced by the ECG and used 
to diagnose cardiac 
problems
Electric Axis of the Heart
This axis changes during cardiac cycle as shown 
earlier – generally lies between +30º and ‐110º in the 
frontal plane and +30º and ‐30º in the transverse 
plane
Clinically, it is generally taken where the QRS 
complex has the largest positive deflection
Note: Often use –aVR
Deviation to R: increased activity in R vent. –
obstruction in lung, pulmonary emboli, some heart 
disease
Deviation to L: increased activity in L vent. –
hypertension, aortic stenosis, ischemic heart disease
NORMAL SINUS RHYTHM
Impuses originate at S-A node at normal rate
SINUS TACHYCARDIA
Impuses originate at S-A node at rapid rate
All complexes normal, evenly spaced
Rate > 100/min
SINUS TACHYCARDIA
Impuses originate at S-A node at rapid rate
All complexes normal, rhythm is irregular
Longest R-R interval exceeds shirtest > 0.16 s
ATRIAL FLUTTER
Impulses travel in circular course in atria – No interval between T and P
Rapid flutter waves, ventricular response irregular
ATRIAL FIBRILLATION
Impuses have chaotic, random pathways in atria
Baseline irregular, ventricular response irregular
PREMATURE VENTRICULAR CONTRACTION
A single impulse originates at right ventricle
Time interval between normal R peaks
is a multiple of R-R intervals
VENTRICULAR TACHYCARDIA
Impulse originate at ventricular pacemaker – odd/wide QRS complex - often due to myocardial infarction
Wide ventricular complexes
Rate> 120/min
VENTRICULAR FIBRILLATION
Chaotic ventricular depolarization – ineffective at pumping blood – death within minutes
Rapid, wide, irregular ventricular complexes
PACER RHYTHM
Impulses originate at transvenous pacemaker
Wide ventricular complexes preceded by pacemaker spike
Rate is the pacer rhythm
A-V BLOCK, FIRST DEGREE
Atrio-ventricular conduction lengthened
P-wave precedes each QRS-complex but PR-interval is > 0.2 s
A-V BLOCK, SECOND DEGREE
Sudden dropped QRS-complex
Intermittently skipped ventricular beat
RIGHT BUNDLE-BRANCH BLOCK
QRS duration greater than 0.12 s
Wide S wave in leads I, V5 and V6
RIGHT ATRIAL HYPERTROPHY
Tall, peaked P wave in leads I and II
LEFT ATRIAL HYPERTROPHY
Wide, notched P wave in lead II
Diphasic P wave in V1
LEFT VENTRICULAR HYPERTROPHY
Large S wave in leads V1 and V2
Large R wave in leads V6 and V6
Myocardial Ischemia and Infarction
• Oxygen depletion to heart can 
cause an oxygen debt in the 
muscle (ischemia)
• If oxygen supply stops, the 
heart muscle dies (infarction)
• The infarct area is electrically 
silent and represents an 
inward facing electric 
vector…can locate with ECG
 The normal electrocardiogram (ECG) pattern consists 
of a P wave, a QRS complex, and a T wave (A). The 
portion of the ECG between the QRS complex and the 
T wave is called the ST segment. In patients who have 
an ST elevation most probably have myocardial 
infarction (MI), the ST segment is elevated above the 
baseline (B). In patients who have a non‐ST elevation 
MI, the ST segment is not elevated, and instead other 
patterns are seen (for example, ST depression) (C).
 Thank you for your attention
Pulmonary Function Tests
Dave Utulu
Objectives
• Review basic pulmonary anatomy and
physiology.
• Understand the reasons pulmonary function
tests (PFTs) are performed.
• Understand the technique and basic
interpretation of spirometry.
• Know the difference between obstructive
and restrictive lung disease.
• Know how PFTs are clinically applied.
Before you can proceed, you need
to know a little about the lungs…
What do the lungs do?
• Primary function is gas exchange
• Let oxygen move in
• Let carbon dioxide move out
How do the lungs do this?
• First, air has to move to the region where
gas exchange occurs.
• For this, you need a normal ribcage and
respiratory muscles that work properly
(among other things).
Conducting Airways
• Air travels via laminar
flow through the
conducting airways
comprised of the
following: trachea, lobar
bronchi, segmental
bronchi, subsegmental
bronchi, small bronchi,
bronchioles, and terminal
bronchioles.
How do the lungs do this? (cont)
• The airways then branch further to
become transitional/respiratory
bronchioles.
• The transitional/respiratory zones are
made up of respiratory bronchioles,
alveolar ducts, and alveoli.
How do the lungs do this? (cont)
• Gas exchange takes place in the acinus.
• This is defined as an anatomical unit of the
lung made of structures supplied by a
terminal bronchiole.
From Netter
Atlas of
Human
Anatomy,
1989
How does gas exchange occur?
• Numerous capillaries are wrapped around
alveoli.
• Gas diffuses across this alveolar-capillary
barrier.
• This barrier is as thin as 0.3 μm in some
places and has a surface area of 50-100
square meters!
Gas Exchange
What exactly are PFTs?
• The term encompasses a wide variety of objective
methods to assess lung function. (Remember that the
primary function is gas exchange).
• Examples include:
– Spirometry
– Lung volumes by helium dilution or body plethysmography
– Blood gases
– Exercise tests
– Diffusing capacity
– Bronchial challenge testing
– Pulse oximetry
Why do I care about PFTs?
• Add to diagnosis of disease (pulmonary
and cardiac)
• May help guide management of a disease
process
• Can help monitor progression of disease
and effectiveness of treatment
• Aid in pre-operative assessment of certain
patients
Yes, PFTs are really wonderful
but…
• They do not act alone.
• They act only to support or exclude a
diagnosis.
• A combination of a thorough history and
physical exam, as well as supporting
laboratory data and imaging will help
establish a diagnosis.
Where would I perform PFTs?
• At home--peak expiratory flow meter/pulse
ox
• Doctor’s office
• Formal PFT laboratory
When would I order PFTs?
• INDICATIONS FOR SPIROMETRY
• Diagnostic
• To evaluate symptoms, signs, or abnormal
laboratory tests
• -Symptoms: dyspnea, wheezing, orthopnea,
cough, phlegm production,
• chest pain
• -Signs: diminished breath sounds, overinflation,
expiratory slowing,
• cyanosis, chest deformity, unexplained crackles
• -Abnormal laboratory tests: hypoxemia,
hypercapnia, polycythemia,
• abnormal chest radiographs
• To measure the effect of disease on pulmonary
function
• To screen individuals at risk of having pulmonary
diseases
• -Smokers
• -Individuals in occupations with exposures to
injurious substances
• -Some routine physical examinations
• To assess preoperative risk
• To assess prognosis (lung transplant, etc.)
• To assess health status before enrollment in
strenuous physical activity
• programs
• Monitoring
• To assess therapeutic interventions
• -bronchodilator therapy
• -Steroid treatment for asthma, interstitial lung
disease, etc.
• -Management of congestive heart failure
• -Other (antibiotics in cystic fibrosis, etc.)
• To describe the course of diseases affecting lung
function
• -Pulmonary diseases
• Obstructive airways diseases
• Interstitial lung diseases
• -Cardiac diseases
• Congestive heart failure
• -Neuromuscular diseases
• Guillain-Barre Syndrome
• To monitor persons in occupations with exposure
to injurious agents
• To monitor for adverse reactions to drugs with
known pulmonary toxicity
(From ATS, 1994)
When would I order PFTs
(cont)?
• Disability/Impairment Evaluations
• To assess patients as part of a rehabilitation program
• -Medical
• -Industrial
• -Vocational
• To assess risks as part of an insurance evaluation
• To assess individuals for legal reasons
• -Social Security or other government compensation programs
• -Personal injury lawsuits
• -Others
• Public Health
• Epidemiologic surveys
• -Comparison of health status of populations living in different
• environments
• -Validation of subjective complaints in occupational/environmental
• settings
• Derivation of reference equations
(From ATS, 1994)
Spirometry
Spirometry is a medical test that measures
the volume of air an individual inhales or
exhales as a function of time.
A Brief Aside on History
• John Hutchinson (1811-1861)—inventor of the
spirometer and originator of the term vital
capacity (VC).
• Original spirometer consisted of a calibrated bell
turned upside down in water.
• Observed that VC was directly related to height
and inversely related to age.
• Observations based on living and deceased
subjects.
A Brief Aside on History
• Hutchinson thought it could apply to life
insurance predictors.
• Not really used much during his time.
• Hutchinson moved to Australia and did not
pursue any other work on spirometry.
• Eventually ended up in Fiji and died (possibly of
murder.)
Silhouette of Hutchinson
Performing Spirometry
From
Chest,
2002
Lung Volumes
• Tidal Volume (TV): volume of
air inhaled or exhaled with
each breath during quiet
breathing
• Inspiratory Reserve Volume
(IRV): maximum volume of air
inhaled from the endinspiratory
tidal position
• Expiratory Reserve Volume
(ERV): maximum volume of
air that can be exhaled from
resting end-expiratory tidal
position
Lung Volumes
• Residual Volume
(RV):
– Volume of air
remaining in lungs
after maximium
exhalation
– Indirectly measured
(FRC-ERV) not by
spirometry
Lung Capacities (cont.)
• Functional Residual
Capacity (FRC):
– Sum of RV and ERV or the
volume of air in the lungs at
end-expiratory tidal position
– Measured with multiplebreath
closed-circuit helium
dilution, multiple-breath
open-circuit nitrogen
washout, or body
plethysmography (not by
spirometry)
What information does a
spirometer yield?
• A spirometer can be used to measure the
following:
– FVC and its derivatives (such as FEV1, FEF 25-75%)
– Forced inspiratory vital capacity (FIVC)
– Peak expiratory flow rate
– Maximum voluntary ventilation (MVV)
– Slow VC
– IC, IRV, and ERV
– Pre and post bronchodilator studies
Forced Expiratory Vital Capacity
• The volume exhaled after a subject inhales
maximally then exhales as fast and hard as
possible.
• Approximates vital capacity during slow
expiration, except may be lower (than true VC)
patients with obstructive disease
How is this done?
Performance of FVC maneuver
• Check spirometer calibration.
• Explain test.
• Prepare patient.
– Ask about smoking, recent illness, medication
use, etc.
(adapted from ATS,
1994)
Performance of FVC maneuver
(continued)
• Give instructions and demonstrate:
– Show nose clip and mouthpiece.
– Demonstrate position of head with chin
slightly elevated and neck somewhat
extended.
– Inhale as much as possible, put mouthpiece in
mouth (open circuit), exhale as hard and fast
as possible.
– Give simple instructions.
(adapted from ATS,
1994)
Performance of FVC maneuver
(continued)
• Patient performs the maneuver
– Patient assumes the position
– Puts nose clip on
– Inhales maximally
– Puts mouthpiece on mouth and closes lips around
mouthpiece (open circuit)
– Exhales as hard and fast and long as possible
– Repeat instructions if necessary –be an effective
coach
– Repeat minimum of three times (check for
reproducibility.)
(adapted from ATS, 1994)
Special Considerations in Pediatric
Patients
• Ability to perform spirometry dependent on
developmental age of child, personality,
and interest of the child.
• Patients need a calm, relaxed environment
and good coaching. Patience is key.
• Even with the best of environments and
coaching, a child may not be able to
perform spirometry. (And that is OK.)
Flow-Volume Curves and
Spirograms
• Two ways to record results of FVC maneuver:
– Flow-volume curve---flow meter measures
flow rate in L/s upon exhalation; flow plotted
as function of volume
– Classic spirogram---volume as a function of
time
Normal Flow-Volume Curve and
Spirogram
Spirometry Interpretation: So what
constitutes normal?
• Normal values vary and depend on:
– Height
– Age
– Gender
– Ethnicity
Acceptable and Unacceptable
Spirograms (from ATS, 1994)
Measurements Obtained from the
FVC Curve
• FEV1---the volume exhaled during the first second of the
FVC maneuver
• FEF 25-75%---the mean expiratory flow during the
middle half of the FVC maneuver; reflects flow through
the small (<2 mm in diameter) airways
• FEV1/FVC---the ratio of FEV1 to FVC X 100 (expressed
as a percent); an important value because a reduction of
this ratio from expected values is specific for obstructive
rather than restrictive diseases
Spirometry Interpretation:
Obstructive vs. Restrictive Defect
• Obstructive Disorders
– Characterized by a
limitation of expiratory
airflow so that airways
cannot empty as rapidly
compared to normal (such
as through narrowed
airways from
bronchospasm,
inflammation, etc.)
Examples:
– Asthma
– Emphysema
– Cystic Fibrosis
• Restrictive Disorders
– Characterized by reduced
lung volumes/decreased
lung compliance
Examples:
– Interstitial Fibrosis
– Scoliosis
– Obesity
– Lung Resection
– Neuromuscular diseases
– Cystic Fibrosis
Normal vs. Obstructive vs.
Restrictive
(Hyatt,
2003)
Spirometry Interpretation:
Obstructive vs. Restrictive Defect
• Obstructive Disorders
– FVC nl or↓
– FEV1 ↓
– FEF25-75% ↓
– FEV1/FVC ↓
– TLC nl or ↑
• Restrictive Disorders
– FVC ↓
– FEV1 ↓
– FEF 25-75% nl to ↓
– FEV1/FVC nl to ↑
– TLC ↓
Spirometry Interpretation: What do
the numbers mean?
• FVC
• Interpretation of %
predicted:
– 80-120% Normal
– 70-79% Mild reduction
– 50%-69% Moderate
reduction
– <50% Severe reduction
FEV1
Interpretation of %
predicted:
– >75% Normal
– 60%-75% Mild obstruction
– 50-59% Moderate
obstruction
– <49% Severe obstruction
• <25 y.o. add 5% and >60
y.o. subtract 5
Spirometry Interpretation: What do
the numbers mean?
• FEF 25-75%
• Interpretation of %
predicted:
– >79% Normal
– 60-79%Mild
obstruction
– 40-59%Moderate
obstruction
– <40% Severe
obstruction
• FEV1/FVC
• Interpretation of
absolute value:
– 80 or higher
Normal
– 79 or lower
Abnormal
What about lung volumes and
obstructive and restrictive disease?
(From Ruppel,
2003)
Maximal Inspiratory Flow
• Do FVC maneuver and then inhale as
rapidly and as much as able.
• This makes an inspiratory curve.
• The expiratory and inspiratory flow volume
curves put together make a flow volume
loop.
Flow-Volume Loops
(Rudolph and
Rudolph, 2003)
How is a flow-volume loop helpful?
• Helpful in evaluation of air flow limitation on inspiration
and expiration
• In addition to obstructive and restrictive patterns, flowvolume
loops can show provide information on upper
airway obstruction:
– Fixed obstruction: constant airflow limitation on inspiration and
expiration—such as in tumor, tracheal stenosis
– Variable extrathoracic obstruction: limitation of inspiratory flow,
flattened inspiratory loop—such as in vocal cord dysfunction
– Variable intrathoracic obstruction: flattening of expiratory limb; as
in malignancy or tracheomalacia
Spirometry Pre and Post
Bronchodilator
• Obtain a flow-volume loop.
• Administer a bronchodilator.
• Obtain the flow-volume loop again a minimum of
15 minutes after administration of the
bronchodilator.
• Calculate percent change (FEV1 most
commonly used---so % change FEV 1= [(FEV1
Post-FEV1 Pre)/FEV1 Pre] X 100).
• Reversibility is with 12% or greater change.
Case #1
Case #2
Case #3
Case #4
If you see a patient with cough
and symptoms of breathing
problems connected to airways
and lungs,then this presentation
will be very useful.
Thanks a lot for your time...
Goodluck everyone!!!
Take home message...
Points of Discussion:
 Revising Anatomy Structures
 What is intubation?
 What is the purpose of intubation?
 Is there more than one type of intubation?
 How´s the correct technique?
 What kind of instruments are used?
 What are the main complications of intubation?
 Laryngeal Masks
Anatomy
Mallampati Classification
Definitions
Endotracheal intubation is a procedure by
which a tube is inserted through the
mouth down into the trachea (the large
airway from the mouth to the lungs).
Before surgery, this is often done under
deep sedation. In emergency situations,
the patient is often unconscious at the
time of this procedure.
Main Goal / Purpose of Endotracheal Intubation
 The endotracheal tube serves as an open passage through the upper airway.
 The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to
ventilate the lungs.
 Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can
help when a patient is unconscious and by maintaining a patent airway, especially during surgery.
 It is often used when patients are critically ill and cannot maintain adequate respiratory function to
meet their needs.
How do i decide to Intubate? – Indications -
1. Inadequate oxygenation (decreased arterial
PO2, etc.) that is not corrected by
supplemental oxygen supplied by mask
2. Inadequate ventilation (increased arterial
PCO2)
3. Need to control and remove pulmonary
secretions (bronchial toilet)
4. Need to provide airway protection in a
patient with a depressed gag reflex (for
example during a general anesthesia).
Do not Intubate... – Contraindications -
1. Severe airway trauma or obstruction that does not
permit safe passage of an endotracheal tube.
2. Cervical spine injury, in which the need for complete
immobilization of the cervical spine makes endotracheal
intubation difficult.
Preparing the Procedure
Essentials that must be present to ensure a safe intubation.
They can be remembered by the mnemonic SALT
 Suction. This is extremely important. Often patients will have material in the pharynx, making
visualization of the vocal cords difficult.
 Airway. the oral airway is a device that lifts the tongue off the posterior pharynx, often making
it easier to mask ventilate a patient. The inability to ventilate a patient is bad. Also a source of
O2 with a delivery mechanism (ambu-bag and mask) must be available.
 LLaryngoscopearyngoscope. This lighted tool is vital to placing an endotracheal tube.
 TTubeube. Endotracheal tubes come in many sizes. In the average adult a size 7.0 or 8.0 oral
endotracheal tube will work just fine.
Instruments used...
1. Self-refilling bag-valve
combination (eg, Ambu bag) or
bag-valve unit (Ayres bag),
connector, tubing, and oxygen
source. Assemble all items before
attempting intubation.
2. Laryngoscope with curved
(Macintosh type) and straight
(Miller type) blades of a size
appropriate for the patient.
3. Endotracheal tubes of several
different sizes. Low-pressure,
high-flow cuffed balloons are
preferred.
5. Tincture of benzoin and precut tape.
6. Introducer (stylets or Magill forceps).
7. Suction apparatus (tonsil tip and catheter
suction).
8. Syringe, 10-mL, to inflate the cuff.
9. Mucosal anesthetics (eg, 2% lidocaine)
10. Water-soluble sterile lubricant.
11. Gloves.
Instruments used... (II)
TECHNIQUE
Topical Anesthesia: Anesthetize the mucosa
of the oropharynx, and upper airway with
lidocaine 2%, if time permits and the
patient is awake.
Direct Laryngoscopy:
1. Place the patient in the sniffing position.
2. Check the laryngoscope and blade for
proper fit, and make sure that the light
works.
3. Make sure that all materials are assembled
and close at hand.
MADgicWand™ Mucosal Atomization Device
for atomizing topical solutions. With 5mL syringe
a) Open the patient's mouth with the right
hand, and remove any dentures.
b) Grasp the laryngoscope in the left hand
c) Spread the patient's lips, and insert the
blade between the teeth, being careful not
to break a tooth.
d) Pass the blade to the right of the tongue,
and advance the blade into the
hypopharynx, pushing the tongue to the
left.
e) Lift the laryngoscope upward and
forward, without changing the angle of the
blade, to expose the vocal cords.
Curved blade technique
f) The anesthesiologist then takes the endotracheal tube, made of flexible plastic, in the right
hand and starts inserting it through the mouth opening.
g) The tube is inserted through the cords to the point that the cuff rests just below the cords
h) Finally, the cuff is inflated to provide a minimal leak when the bag is squeezed
Using a stethoscope , the anesthesiologist listens for breathing sounds to ensure correct
placement of the tube
Document the view of the larynx obtained during laryngoscopy using the following criteria:
Grade I: full view of the cords
Grade II: partial view of the cords
Grade III: view of the epiglottis
Grade IV: No view of the cords or epiglottis
http://www.youtube.com/watch?v=eRkleyIJi9U
Curved blade technique (II)
Straight blade technique
Follow the steps outlined for curved blade technique, but advance the blade down the
hypopharynx, and lift the epiglottis with the tip of the blade to expose the vocal cords.
The tip of the laryngoscope blade fits below the epiglottis, which is no longer visible with the
blade in position.
Complications
1. Tube malpositioning (esophageal intubation )
2. Tube malfunction or physiologic responses to airway instrumentation
3. Trauma such as tooth damage, lip/tongue/mucosal laceration, sore throat,
dislocated mandible
4. Mucosal inflammation and ulceration and excoriation of nose can occur
while the tube is in place
5. Laryngeal malfunction and aspiration, glottic, subglottic or tracheal edema
and stenosis, vocal cord granuloma or paralysis during extubation
Physiologic responses to intubation include hypertension, tachycardia,
intracranial hypertension, and laryngospasm
Laryngeal Masks (LMA)
The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway
support.
 They cause less pain and coughing than an endotracheal tube, and are much easier to insert
It consists of an inflatable silicone mask and rubber connecting tube. It is inserted blindly
into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle
positive pressure ventilation. All parts are latex-free
Indications:
When endotracheal intubation is
not necessary or it’s difficult
Contraindications:
• Non-fasted patients
• Morbidly obese patients
• Obstructive or abnormal
lesions of the oropharynx
Short Procedure:
1. The cuff of the mask is deflated before
insertion and lubricated.
2. The patient is sedated or fully anaesthetized
if conscious, and their neck is extended and
their mouth opened widely.
3. The apex of the mask, with its open end
pointing downwards toward the tongue,
is pushed backwards towards the uvula.
4. The cuff follows the natural bend of the
oropharynx, and its long walls come to rest
over the piriform fossa.
5. Once placed, the cuff around the mask is
inflated with air to create a tight seal.
Air entry is confirmed by
listening for air entry into the
lungs with a stethoscope
Laryngeal Masks (II)
Advantages vs. Disadvantages
Advantages:
•Allows rapid access
•Does not require laryngoscope
•Relaxants not needed
•Provides airway for spontaneous or controlled ventilation
•Tolerated at lighter anesthetic planes
Disadvantages:
• Does not fully protect against
aspiration in the non-fasted patient
• Requires re-sterilization
THANK YOU!
Administration Of Oxygen Therapy
Richard Dolan
Oxygen Therapy.
• Oxygen therapy is the
administration of oxygen as a
medical intervention. For a variety
of purposes in both acute and
chronic patient care.
• Oxygen is essential for cell
metabolism, and in turn, tissue
oxygenation is essential for all
normal physiological functions.
• Room air only contains 21%
oxygen, and increasing the
fraction of oxygen in the breathing
gas increases the amount of
oxygen in the blood.
• It is often only required to raise the
fraction of oxygen delivered to 30–
35% and this is done by use of a
nasal cannula.
Oxygen Therapy.
• When 100% oxygen is needed, it may be
delivered via a tight-fitting face mask, or by
supplying 100% oxygen to an incubator in
the case of infants.
• Oxygen can be administered in other
ways, including specific treatments at
raised air pressure, such as hyperbaric
oxygen therapy.
Indications For Use.
• Chronic conditions, patient
with COPD, a common long
term effect of smoking,
patients need more oxygen
to breathe during a
temporary worsening of this
condition or full time
through day and night.
• Acute conditions, oxygen
used in emergency
medicine, like in
resusitations, major trauma,
anaphylaxis, major
haemorrage, shock and
hypothermia.
Delivery.
• Various devices are used for administration of oxygen.
• Most often, the oxygen will flow through a pressure
regulator, used to control the high pressure of oxygen
delivered from a cylinder, to a lower pressure.
• This lower pressure is then controlled by a flowmeter,
which may be preset or selectable, and this controls the
flow in a measure such as litres per minute (lpm).
• The typical flowmeter range for medical oxygen is
between 0 and 15 lpm with some units able to obtain up
to 25 liters per minute.
Supplemental oxygen.
• Majority of patients require only a
supplementary level of oxygen in the
room air they are breathing, rather
than pure oxygen.
• A nasal cannula (NC) is a thin tube
with two small nozzles that protrude
into the patient's nostrils. It can only
comfortably provide oxygen at low flow
rates, 0.25-6 litres per minute (LPM),
delivering a concentration of 24-40%.
(pic on previous slide).
• Also, the face mask option, such as
the simple face mask!
• Often used at between 5 and 15 LPM,
with a concentration of oxygen to the
patient of between 28% and 50%.
• Venturi masks, which can accurately
deliver a a predetermined oxygen
concentration to the trachea up to
40%.
Supplemental oxygen.
• In some cases,
oxygen can be
delivered using a
partial re breathing
mask, based on a
simple mask but has
a reservoir bag, which
increases the
provided oxygen rate
to 40 – 70% oxygen
at 5 – 15 lpm.
High flow oxygen delivery.
• In cases where the patient requires a flow of up
to 100% oxygen, a number of devices are
available, with the most common being the nonrebreather
mask (or reservoir mask).
• This is similar to the partial rebreathing mask
except it has a series of one-way valves
preventing exhaled air from returning to the bag.
• There should be a minimum flow of 10 L/min.
• The delivered FIO2 of this system is 60-80%,
depending on the oxygen flow and breathing
pattern.
Positive pressure delivery.
• Patients who are unable to breathe on
their own will require positive pressure
to move oxygen in to their lungs for
gaseous exchange to take place.
• Systems for delivering this vary in
complexity (and cost), starting with a
basic pocket mask, which can be used
by a basically trained first aider to
manually deliver artificial respiration
with supplemental oxygen delivered
through a port in the mask.
• Many emergency medical service and
first aid personnel, as well as
hospitals, will use a bag-valve-mask
(BVM), which is a maleable bag
attached to a face mask, usually with a
reservoir bag attached, which is
manually manipulated by the
healthcare professional to push
oxygen (or air) in to the lungs.
Hyperbaric oxygen therapy.
• Therapeutic principle of HBOT lies in
its ability to drastically increase partial
pressure of oxygen in the tissues of
the body. The oxygen partial
pressures achievable using HBOT are
much higher than those achievable
while breathing pure oxygen at
normobaric conditions (i.e. at normal
atmospheric pressure);
• Hyperbaric oxygen therapy (HBOT), is
the medical use of oxygen at a level
higher than atmospheric pressure.
• The increased overall pressure is of
therapeutic value when HBOT is used
in the treatment of decompression
sickness and air embolism.
(Prevention of decompression
syndrome is for the diver to make
decompression stops on his way up to
surface).
Indications for HBOT.
• Air or gas embolism.
• Carbon monoxide poisoning.
• Clostridal myositis and myonecrosis (gas
gangrene)
• Decompression sickness.
• Intracranial abscess
• Big blood loss (anemia).
Oxygen Toxicity.
As a drug delivery route
• Oxygen therapy can also
be used as part of a
strategy for delivering
drugs to a patient.
• The usual example of this
being through a nebulizer
mask, which delivers
nebulizable drugs such
as salbutamol or
epinephrine into the
airways by creating a
vapor-mist from the liquid
form of the drug .
Thanks For Listening
Using a nebulizer and inhaler
correctly.
Richard Dolan
Nebulizer.
• A Nebulizer is a device used to administer
medication to people in the form of a mist
inhaled into the lungs.
• Commonly used in treating cystic fibrosis,
asthma, COPD and other respiratory diseases.
• The common technical principal for all
nebulizers, is to either use oxygen, compressed
air or ultrasonic power, as means to break up
medical solutions/suspensions into small aerosol
droplets, for direct inhalation from the
mouthpiece of the device.
Use and attachments.
• Nebulizers accept their
medicine in the form of a liquid
solution, which is often loaded
into the device upon use.
• Corticosteroids and
Bronchodilators such as
salbutamol are often used.
• The reason these
pharmaceuticals are inhaled
instead of ingested is in order
to target their effect to the
respiratory tract, which speeds
onset of action and reduces
side effects, compared to other
alternative intake routes.
Nebulizer.
• The most commonly used
nebulizers are the Jet
Nebulizers.
• Jet nebulizers are
connected by tubing to a
compressor, that causes
or oxygen to blast at high
velocity through a liquid
medicine to turn it into an
aerosol.
• Aerosol is then inhaled by
the patient.
Inhalers.
• Instead of using nebulizers to
deliver a medical liquid to the
lungs in the form of aerosol
droplets, its also possible to
use inhalers for the same
purpose.
• It is mainly used in the
treatment of asthma and
COPD.
• Pictured is the pressurised
metered dose inhaler (MDI),
the most common type of
inhaler.
Use
• In MDI’s, medication is most commonly
stored in solution in a pressurized canister
that contains a propellant.
• The MDI canister is attached to a plastic,
hand-operated actuator.
• On activation, the metered-dose inhaler
releases a fixed dose of medication in
aerosol form.
Use
• The correct procedure for
using an MDI is to first fully
exhale, place the mouth-piece
of the device into the mouth,
and having just started to
inhale at a moderate rate,
depress the canister to release
the medicine.
• The aerosolized medication is
drawn into the lungs by
continuing to inhale deeply
before holding the breath for
10 seconds to allow the
aerosol to settle onto the walls
of the bronchial and other
airways of the lung.
Categories
• Bronchodilator Inhalers: Short-Acting
Beta-2 Adrenergic Bronchodilator Inhalers
• Daily Inhalers: Long-Acting Adrenergic
Bronchodilator Inhalers
• Daily Inhalers: Anticholinergic
Bronchodilators in COPD
• Daily Inhalers: Corticosteroids
• Combination Inhalers: Corticosteroid with
LongActing Beta-2 Adrenergic Agonist