Invasive Procedures

femoral stick purpose

to obtain blood from the femoral artery or vein for analysis when there is no other peripheral site available

femoral stick contraindications

overlying cellulitis or hematoma

known venous or arterial thrombosis

known graft site

femoral stick anatomical landmarks

pt supine, legs extended

palpate artery 2 fingerbreaths below inguninal ligament

vein 1cm medial to artery

NAVY mnemonic

NAVY mnemonic

Nerve

Artery

Vein

“Y” shape of the groin

femoral stick supplies

20-30cc syringe

19G, 1.5” needle

heparinized syringe if ABG

chlorhexidine

alcohol swab

4×4

tubes for blood analysis

femoral stick preparation

informed consent if not an emergency

assemble needle and syringe

palpate artery w/ left hand, do not remove

swab w/ chloro-prep, allow to dry

swab w/ alcohol (skip if determining EtOH levels)

femoral stick procedure

90 angle to vessel

straight down w/ aspiration until blood withdrawn

withdraw desired amount

apply pressure to artery for at least 10 min

place blood in tubes for analysis

femoral stick complications

hematoma

infection

thromboembolus

septic arthritis of hip

femoral nerve damage

psoas abscess

penetration of viscous

intraosseous line

placement of a line into the marrow cavity of a bone to provide emergency access for medication and fluid resuscitation

intraosseous line placement purpose

emergency “venous” access

provides rapid access only when a peripheral line not available

can administer any fluids, bloods, or meds (except adenosine)

IO line CI

previous attempt in same bone

fracture

overlying infection

IO line anatomical landmarks

sandbag under knee for support

medical surface of tibia

1-3cm below tibial tuberosity

flat portion easily palpable

IO line placement supplies

IO or bone marrow needle

10cc non-leurlock syringe

chloro-prep

IV fluids, assembled w/ tubing

Is informed consent for an IO line necessary?

not necessary as this is a life saving, emergency procedure

IO line placement procedure

insert needle w/ stylet in place at 90 angle to bone using rotating motion

alternatively, 60 angle inferiorly

when resistance “gives way” stop advancing

remove stylet, withdraw marrow

How is IO line placement confirmed?

when marrow is withdrawn, or free flow of IV fluid w/ no evidence of soft tissue extravasation

IO line complications

accidental soft tissue placement

infection

fracture

IO line clinical pearls

No “2nd tries”

tibia, humerus, and sternum are only recommended sites, but iliac crest and distal femur

remove as soon as peripheral line is obtained

max 24 hrs

central venous lines

insertion of large bore catheter into a large proximal vein for administration of fluid or medication

central venous line indications

unable to obtain peripheral access

central venous monitoring - Swan-Ganz, CVP

frequent blood draws

chemotherapy

hyperalimentation

central venous lines anatomy

internal jugular vein

subclavian vein

femoral vein

tip of catheter should be in the SVC for jugular and subclavian placement

IVC below renal veins for femoral placement

central venous line - Internal Jugular

right side preferred

posterior approach just inferior to external jugular, aiming for midsternal notch

anterior approach at apex of triangle b/w 2 heads of SCM and clavicle, aiming for ipsilateral nipple

central venous line - subclavian vein

right side preferred

palpate tubercle of clavicle 1/3 to ½ across

1-2 cm below this spot

aim for sternal notch w/ minimal angle off skin

“Hit” clavicle and use the other hand to coax underneath - pops right into vein

central venous line - femoral vein

same landmarks as femoral stick

angle superiorly

tip of catheter should be in IVC, below renal vessels

central venous lines supplies

central venous kiit - multiple lumen catheters, percutaneous introducers

chlorhexidine, goggles, gown, drapes

flushes and IV fluid for line

dressing kit

central venous lines preparation

always obtain informwed consent unless emergenct

anxiolytics or sedation may be required

locate landmarks

positioning is key

assistant may be required

central venous lines procedure

clean and drape

reconfirm landmarks

local anesthetic

insert catheter using Seldinger technique

draw blood from each port

flush w/ saline, clamp off

suture line in place

Seldinger technique

J-type guide wire curls spontaneously minimizing damage to intima of vessel

should be pointed inferiorly in subclavian approach to prevent wire from going up jugular instead of down into SVC

insert large bore needle w/ syringe attached through skin, constantly withdrawing until venous flashback is obtained, stop advancing and hold needle in place

remove syringe, insert guidewire through needle until only 2-3cm remain protruding, NEVER LET GO OF GUIDE WIRE

remove needle, leaving guide wire in place

enlarge entry point using tip of a scalpel blade

pass dilator through catheter, advance to skin leaving 1-2cm of wire exposed

slowly remove guide wire from skin through catheter until end of wire appears out open end of catheter

advance catheter/dilator complex into vessel, use forward pressure and twisting motion advancing catheter throguh skin to hub od catheter

remove dilator and guide wire simultaneoulsy from catheter

central venous lines aftercare

always confirm venous placement w/ blood draw

if aterial placement suspected, run ABG

CXR to r/o PTX, and confirm placement in SVC

some institutions will not allow use of line until placement confirmed by CXR

central venous lines complications

bleeding - local, internal, and hematoma

infection

PTX, hemothorax, hydrothorax

air, catheter, and venous embolus

arrhythmia

knotting and kinking

Lumbar puncture (LP)

removal of fluid from dural space

LP purpose

to obtain CSF for analysis - meningitis or other neuro dz, subarachnoid hemorrhage

to remove excess fluid (in normal pressure hydrocephalus)

LP CI

cerebral edema - increasing HA

mass lesions - tumor, brain abscess

localizing sxs

rapid deterioration

papilledema

hx or physical suggesting sinusitis, otitis media, or endocarditis

LP anatomical landmarks

L4-L5 or L5-interveterbral space

LP positioning

horizontal line b/w posterior iliac crests localizes proper vertebral space

easiest to locate space when pt is maximally flexed

may also be done when pt is sitting

LP supplies

betadine, gloves, mask, gown, goggles

LP tray - 3cc syringe, 22/25G needles, 1% lidocaine, 25/22G spinal needle, 3-way stopcock, manometer, sterile field, tubes 1-4, 4×4, band-aid

LP preparation

always obtain informed consent

positioning is EVERYTHING

locate landmark and mark w/ fingernail or surgical marking pen

mask and gown

open tray using sterile technique

pour proviodine

gloves

get comdy

prep w/ betadine

drape

LP procedure

find fingernail mark and reconfirm

raise “wheal” w/ lidocaine

inject to bone w/ 3cc of lidocaine changing to larger needle when skin adequately anesthetized

insert spinal needle stylet in, bevel up aiming for umbilicus

when “pop”, remove stylet and check for fluid

if no fluid, reinsert stylet and continue to advance, checking every 1-2mm for penetrance

measure opening pressure

withdraw 4 tubes in succession 1-3cc each

replace stylet and remove needle slowly

hold pressure for several minutes, apply band-aid

LP aftercare

lay flat for 4 hrs, prone vs supine

IV or PO fluids encouraged

caffeine - coffee, coke, no-doze

LP complications

post LP HA

intraspinal epidermoid tumors

epidural, subdural, or SAH

infection

herniation

LP MC tests

tube 1 and tube 4 - CBC

tube 2 and tube 3 - protein, glucose, Gram stain, culture

LP other tests

VDRL

ANA

protein electrophoresis

crypto, toxo, viral cultures

other fungal cultures

cytology

thoracentesis

removal of fluid from thoracic cavity

thoracentesis indications

to withdraw fluid for analysis to aid in dx of pleural effusions (Dx tap)

to decrease pleural volume to adi in adequate ventilation and oxygenation (therapeutic tap)

thoracentesis absolute CI

overlying cellulitis

inability to determine proper anatomy

thoracentesis relative CI

COPd

loculated effusion

small effusion

thoracentesis anatomical landmarks

compare CXR to pt

percuss for dullness to find the fluid level

mid-scapular or posterior axillary line

above rib

thoracentesis supplies

prep sponges

sterile field

10cc syringe w/ 25 and 22G needles

14G angiocath w/ 20cc syringe

sterile IV tubing

vacuum bottle

thoracentesis preparation

informed consent

pt sitting up over bedside table, supplemental oxygen

locate site, mark w/ surgical pen or fingernail

clean skin, sterile drapes

thoracentesis procedure

anesthetize skin, constantly withdrawing

switch to larger needle, perpendicular, constantly withdrawing until pleural fluid return

insert angiocath w/ syringe same distance and withdraw fluid

remove needle from catheter and discard

attach IV tubing (turned off) to angiocath and then vacuum bottle

turn on IV tubing, collect as much fluid as required

remove angiocath, do not reinsert needle

pressure for several minutes, band-aid or occlusive dressing

thoracentesis fluid analysis

cell count

LDH

protein

culture

cytology

amylase

glucose

RF

thoracentesis complications

pneumothorax

draining fistula

bleeding

pulm edema

hypoxia d/t V/Q mismatch

laceration of liver or spleen

abdominal paracentesis

removal of fluid from abdominal cavity

abd paracentesis indications

dx - etiology, infection of pre-exisiting ascites

therapeutic

abd paracentesis CI

overlying cellulitis, surgical scar

full urinary bladder

abd paracentesis anatomical landmarks

avoid rectus sheath and vasculature

infraumbilical approach

L or R LQ

abd paracentesis supplies

prep sponges

sterile field

25 and 22G needle, 10 cc syringe

1% lidocaine

18G angiocath w/ 20 cc syringe

sterile IV tubing, vacuum bottle

abd paracentesis preparation

insert foley catheter

positioning pt on side being tapped encourages bowel away from needle

prep sponges

sterile field

abd paracentesis procedure

anesthesize area

insert 18G angiocath “Z” track if possible

constant drawback

withdraw and try again if no return

extract fluid similar to thoracentesis

abd paracentesis fluid analysis

cell count

protein

LDH

glucose protein cytology

culture

abd paracentesis complications

bleeding

infections

leak

vascular collapse and renal failure

hyponatremia

anterior nasal packing

stopping epistaxis

anterior nasal packing indications

to arrest hemorrhage in epistaxis - nose pickers, infections, dryness, vascular abnormalities, coagulation disorders, neoplasms

anterior nasal packing CI

sig facial fractures

posterior bleed should be handled by ENT

recurrent bleeds should be handled by ENT

anterior nasal packing anatomy

Kisselbach’s plexus

anterior ethmoidal artery

perforating branches of sphenopalatine artery

anterior nasal packing supplies

head lamp, goggles, gown

nasal speculum

appropraite size bayonet forceps

topical epinephrine or cocaine

2×2 gauze or cotten pledgets

vaseline gauze packing

antibiotic ointment

suction

anterior nasal packing preparation

pt sitting upright w/ head forward and nose pinched for 10 mins

attempt to control HTN if present

anxiolytics if required

IV access, blood work if required

anterior nasal packing procedure

ask pt to blow nose forcefully to remove any clots that may be acting as wicks

inspect both nares w/ speculum to attempt to localize bleeding

pumping arterioles may require cautery w/ sliver nitrate

excessive bleeding may require topical epinpehrine or cocaine before packing

smear abx ointment on packing

anterior nasal packing procedure - detailed

insert packing, looping into nare, layering from inferior to superior

pack firmly going deep to bend of bayonets

6-9 ft of packing should be used

never pack both side simultaneously

secure end w/ gauze and tape

anterior nasal packing - if underpack

decrease the amount of packing which can be inserted

all bleeding points may not be compressed

anterior nasal packing complications

continued bleeding - improper packing, posterior bleed

septal necrosis

infection

some pts fail to tolerate the packing

arterial line placement indications

hemodynamic monitoring

frequent ABGs

frequent lab draws

arterial line placements

radial artery - MC

femoral artery

brachial artery

arterial line pearls

(+) Allens test

sterile technique

recheck circulation after inserting

ultrasound guidance

Seldinger technique