LaSt wEEk-Endotracheal Intubation and Intravenous cannulation
· Endotracheal intubation
· Indicated in cardiac arrest, serious head injury, certain acute respiratory and trauma settings, and prior to many surgical operations
- Effective bag and mask ventilation is better than multiple attempts at endotracheal intubation in the arrest setting.
- Except in a dire emergency endotracheal intubation should not be performed without expert supervision.
Equipment:
• 10mL syringe.
• Endotracheal tube (ET; size 8-9 for females and 9-11 for males).
• Laryngoscope.
• Ribbon to secure tube; lubricating jelly
Steps:
• Pre-oxygenate the patient.
• Ensure that the laryngoscope and ET cuff are functioning.
• Remove any dentures, and suction excess saliva and secretions.
• Extend the neck.
• Insert the laryngoscope pushing the tongue to the left.
• Advance the scope anterior to the epiglottis and pull gently but firmly upwards to expose the vocal cords. Take care not to lever on the upper teeth with the scope.
• Insert the lubricated ET tube between the cords into the trachea.
• Confirm correct positioning of the tube by observing chest movements, and listening over lung bases and stomach.
• Progressively inflate the cuff and attach ventilation equipment.
• Confirm correct cuff inflation by listening for whistling or bubbling in the larynx suggesting air leak and secure the tube in place with ribbon.
• * Patients not in cardiac arrest or who maintain a gag reflex will need anesthetizing prior to oropharyngeal intubation, i.e. administration of inducing agent plus muscle relaxant.
• * The best setting to learn intubation is preoperatively in the anesthetic room of a theater with good supervision in controlled conditions.
and .....
Intravenous cannulation
A similar skill to that of simple venepuncture but needs plenty of practice to become competent. If having difficulty, observe a few experts in action.
Indications
Venous access for administration of IV fluids, blood, or IV drugs.
Equipment
• Tourniquet.
• Cannula: 20G or 18G.
• Adhesive dressing/tape.
• Alcohol swabs.
• 5mL syringe containing 0.9% saline or heparinized saline.
• IV fluid bag with giving set, if necessary.
Preparation
Apply tourniquet above or below the elbow and inspect the arm for suitable engorged veins.
Method
• Clean the skin thoroughly at the site of access.
• Identify a suitable vein.
• Tether the skin distal to the proposed site of puncture.
• Pass the cannula obliquely through the skin at a point approximately 1cm distal to the point at which you wish to enter the vein.
• Advance the cannula smoothly until the vein is entered: a flashback seen in the hub of the cannula.
• Hold the hub of the needle with one hand and advance the cannula into the vein, while maintaining skin fixation until the cannula is well into the vein.
• Remove the tourniquet and press on the vein proximal to the cannula as the needle is removed. Apply the screw cap to the end of the cannula.
• Secure the cannula in place with a dressing.
• If the cannula is not going to be used immediately, flush with heparinized saline
Tips
- Poor veins. If
the patient is cold and the samples non-urgent, place the arm in warm
water and this may aid venous dilatation. Veins on the dorsum of the hand
may be the only ones readily available-try using a smaller or butterfly
needle to obtain samples.
- Obese patients.
Try the dorsum of the hand or the radial aspect of the wrist; access may
be easier here.
- Failed attempts.
Repeated failed attempts will distress the patient and demoralize the
doctor! Ask someone to help. If the samples are extremely urgent, a
femoral stab may be the best option for obtaining blood samples, e.g.
during cardiac arrest.
- IV cannulae. If
blood samples and IV access are needed, a sample can be taken immediately
after inserting the cannula. However, do not use a peripheral cannula for
routine samples; they can be haemolysed, contaminated by IV fluids, and
unreliable.
- Agitated or
fitting patients. Try not to place the cannula over a joint, as these tend
to become easily dislodged
- Secure the
cannula. Cannulas are all too easily dislodged because of poor fixation to
the skin. Use of two cannula dressings (one placed above and one below)
and a bandage is often needed.
- Hairy arm.
Shaving the skin at the planned cannula site seems tedious but will allow
the cannula to be secured adequately.
- Non-dominant
hand. Placing the cannula in the non-dominant hand, if possible, will
allow the patient a little bit more freedom and may prevent the cannula
becoming dislodged easily.
- Fragile veins.
This tends to be a problem in elderly or debilitated patients. Try using a
smaller cannula: the dorsum of the hand is often an ideal site.
- Poor peripheral
access. In some patients with multiple collapsed or damaged veins
alternative cannula sites may have to be considered, e.g. feet. If
peripheral cannulation becomes impossible, a central line will have to be
considered.
- Blood
transfusion. If blood is being given IV then an 18G or 16G cannula will be
needed.
Size and function of different cannulae
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before I end this post..
Last Week:
Wonder how this happen.(.it is a button)
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| This made to go back that day.. |
missing them..
during free time..
by Lakdhes..
Heel Pain Management
Heel Pain Management
heel pain/foot pain/feet pain/leg pain
Plantar fascitis , also known as Plantar Heel Pain (PHP) is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on the sole (bottom surface) of the foot. It is often caused by overuse of the plantar fascia, increases in activities, weight or age. It is a very common condition and can be difficult to treat if not looked after properly.
Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. Since tendons and ligaments do not contain blood vessels, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.
The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes. It is commonly associated with long periods of weight bearing and much more prevalent with hyper-pronation (flat feet). Among non-athletic populations, it is associated with a high body mass index. The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin (decreased dorsiflexion of the ankle). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee pains, especially among runners
An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur; the plantar fasciitis is not caused by the spur.
Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle (FDB) belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.
Treatment
Physical treatments
Based on current research, recommendations for immediate relief and reduction of inflammation include heel and foot stretching exercises as can be tolerated, microcurrent treatment, rest, wearing shoes with good support and cushions. Other steps to relieve pain include: applying ice or ice-heat-ice, and/or using night splints to stretch the injured fascia. Customized functional foot orthotics can offer a decrease in the pain associated with plantar fasciitis and may provide an additional benefit in terms of increased functional ability in patients with the condition.
Some evidence shows that stretching of the calf and plantar fascia may provide up to 2–4 months of benefit. One study has shown improvement over a four-month period with stretching. One study has shown high success rates with a stretch of the plantar fascia, but has been criticized because it was not blinded, and contained a bias because the analysis did not use the intention to treat method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo effects.
Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.
Surgery
Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain.This allows more space for the inflamed muscle belly, thus, relieving pain/pressure. An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.Coblation surgery has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.
Medication
To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit.Dexamethasone 0.4 % or acetic acid 5% delivered by iontophoresis(Iontophoresis is a physical process in which ions flow diffusively in a medium driven by an electric field to treat of excessive sweating of the hands and feet ) combined with low Dye strapping and calf stretching has been shown to provide short term pain relief and increased function.
Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle.(Injecting dexamethasone and lidocaine ,but dont try yourself).Recurrence rates may be lower if injection is performed under ultrasound guidance.Repeated steroid injections may result in rupture of the plantar fascia.
by Lakdhes..
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If you're reading this,first of all congratz.Now let's get into business.What I'm going to share here is basically my mistakes...
