Plaster Removal

 PLASTER REMOVAL

GENERAL GUIDELINES: 

Reassure patient and inform that the saw blade may get hot.

1. Support and position limb.

2. The noise of the electric cutter frightens some children, and so shears may be used.

3. A plastic skin protector strip may be inserted between the cast lining and a patient’s limb in the area where cutting will occur to protect the skin.

4. Cut steadily and smoothly while conversing with the patient to divert attention.

REMOVAL OF PLASTER CAST WITH STILLE’S PLASTER SHEARS:

1. Draw guidelines down the side of the cast making sure that the line does not run directly over any bony prominences. 

2. Insert the blade between the plaster and the padding wool, parallel to the skin with the handle held steadily in the vertical position. The other blade cuts through the cast from above, its handle should be parallel to the cutting line at rest. 

This is the starting position, and if the blades are incorrectly aligned, the lower blade will press into the flesh causing bruises or even lacerations.

3. After each cut, the blades should be realigned before the next cut is made. This prevents the skin wrinkling in front of the shears. 

4. Use the plaster benders to open out the cast.

5. Use scissors to cut the guaze padding. 

REMOVAL OF PLASTER CAST WITH ELECTRIC CUTTER (MORE COMMONLY DONE):

1. The electric cutter must only be used to cut completely padded casts.

2. Position the blade at the start of the guideline, apply gentle pressure and move the cutter smoothly along the line. 

   
   

3. The electric cutter should always be used carefully especially near bony prominences such as the medial border of the foot leading to the big toe. 

4. Rest of the procedure is same as above.

CARE OF THE PART AFTER CAST REMOVAL:

• Examine for any injury.

• Instructions for the patient:

1. Wash and dry the part.

2. Gentle massage with oil, or cream, may help to restore normal nutrition and elasticity to the skin.

3. Some swelling of the limb is expected after a period of immobilization, especially in the lower limbs.Excessive swelling may be managed by elastic wrapping or intermittent limb elevation.

4. Continue exercises as advised and resume normal activity gradually, resting the part at regular intervals.

Practical tips and tricks:

1. Never try to cut around corners. Always remove the blades and cut from the opposite end of the line to meet the end of the cut already made.

2. When using shears, keep the elbows relatively still and apply the cutting force from the shoulder girdle and chest muscles. This gives a more controlled power and saves energy.

REFERENCE VIDEO LINK:

Plaster cutting with electric cutter: https://youtu.be/3yW_-Aq0O0Q 

Written by our guest author - Rishabh Rawat

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

 

Thoracocentesis

THORACOCENTESIS 

REQUIREMENTS:  

Written Informed Consent, Sterile gloves, povidone iodine solution, aspiration needle, 3 way stop cock, one 5 mL (for LA) and one 20 mL or 50 mL syringe, a reservoir (empty plastic bottle), one non-collapsible tube (iv set can be used for this), injection lignocaine and sterile dressing

PROCEDURE:

1. Check the vitals of the patient.

2. Position of the patient

(Sitting leaning forward with hands on the table)

• If no table is available, ask the patient to cross their arms in front of their chest.
• If the patient is unable to sit up, the lateral recumbent or supine position may be used. 

 

2. IV access should be established before procedure in most cases. 

3. Atropine should be on hand in case of profound vaso-vagal response and supplemental O2 should be administered throughout the procedure. It is given as IM routinely pre-procedure. 

4. Confirm the side by looking at the chest radiograph or sonography report) 

5. The skin at the puncture site will be cleansed with an antiseptic solution like povidone iodine. 

6. SITE: 7th or 8th intercostal space between the inferior angle of scapula (Aspiration site is determined by USG when done electively or by percussion when done during emergency.)  

7. Give local anesthesia. Infiltrate the skin and subcutaneous tissue and the parietal pleura over the chosen space at the upper border of the lower rib.   

8. The needle has to be inserted near the upper border of lower rib in the intercoastal space.

9. Insert the needle with the stop cock in closed position piercing the skin, subcutaneous tissue and the pleura. A 20 or 50 mL syringe is connected to the end of the stop cock and by turning the stop cock to on position, fluid is aspirated gently with the syringe (figure 1). The stop cock is turned on to the side channel and the fluid is pushed out from the syringe to the reservoir (usually a plastic bottle) via the side channel (figure 2). The process of aspiration is then repeated by turning the stop cock to on position. 

NEVER OPEN THE SIDE PORT ATTACHED TO TUBE DIRECTLY TO PLEURAL SPACE. (To avoid pneumothorax)

                                                

Figure 1- Showing the position of the 3-way during aspiration of pleural fluid

Figure 2- Showing the position of the 3-way while pushing out the fluid into reservoir

Not more than 1000 mL of fluid from pleural cavity is removed within first 30 minutes if done for therapeutic purpose (to prevent re-expansion pulmonary edema). 40-50 mL fluid is sufficient if done for diagnostic purposes. The fluid may be sent to a laboratory for testing (pleural fluid analysis). 

Place a small sterile dressing over the site of puncture.

  

10. Post-procedure X-ray to evaluate the fluid level.

VIDEO LINK:

https://youtu.be/2FviyY_XrEU

 

 

Written by our guest authors - Aishwarya Bagade and Ayushi Gupta 

Illustration by Anveshi Nayan 

#Ae(ONE)INTERN

 

 

CARDIOPULMONARY RESUSCITATION (CPR)

 CARDIOPULMONARY RESUSCITATION (CPR)

OUTSIDE HOSPITAL CPR

PRE- CPR PROCEDURE:

1. First, check the scene for factors that could put you in danger, such as traffic, fire, or falling masonry.

2. Next, check the person. Tap their shoulder and shout, "Are you OK?”. If they are not responding, call for help and call 108. If available, ask a near-by person to bring AED machine.

3. 
   

Remove any obstruction (food or vomitus) seen, only if it is loose. 

(If it is not loose, trying to grasp it may push it farther into the airway.)

• Check for breathing and feel for pulse (Brachial artery in infant, Carotid or femoral in a child and Carotid in adults) within 10 seconds:

  
  

  

  
  

1. No breathing, or occasional gasps + No pulse           Begin CPR

2. No breathing or occasional gasps + Pulse felt         Give 10-12 breaths/ minute

3. Unconscious but still breathing, do not perform CPR. Instead, place them in:

Keep monitoring the patient. Start CPR if the person stops breathing.

CPR

4. Perform chest compressions at the rate of 100-120/ min:

5. Open airway using triple maneuver: 

6. Give rescue breaths:

Pinch the nose while giving a breath mouth-to-mouth and look for chest rise.

If their chest does not rise with the first breath, tilt their head.

If their chest still does not rise with a second breath, the person might be choking. 

7. Try to synchronize the breaths with any voluntary breathing activity of the patient that might be present.

8. Repeat the cycle of 30 chest compressions and two rescue breaths until the person starts breathing or help arrives. If an AED arrives, carry on performing CPR until the machine is set up and ready to use. 

FOR CHILDREN (STEPS AS ABOVE WITH FOLLOWING MODIFICATIONS)

For children, give compressions using one hand only, between the nipples and press down around 2 inches.

For infants, give compressions using both the thumbs or index and middle fingers and press down approximately 1.5 inches.

If two rescuers present, try give 15 compressions followed by 2 rescue breaths and so on.

INSIDE HOSPITAL CPR

1. Recognize cardiac arrest and activate emergency team.

2. Start CPR as above (except that now, the person administering CPR should stand by the side of patient). 

3. Instead of using mouth-to-mouth for rescue breaths (may not feasible in case of infectious diseases), bag and mask ventilation is done and the patient is ventilated with a compression to ventilation ratio of 30:2

For Bag and mask ventilation, tilt the head of patient backwards.

Then, form a tight seal with the mask around the nose and mouth of patient forming letters E by fingers and thumb of one hand and C by the other.

Squeeze the AMBU bag and look for chest rise.

4. Airway may be secured by following methods while making sure that this process doesn’t compromise on the chest compressions.

• Combitube

• Laryngeal Mask Airway

• Endo-tracheal intubation (See document titled ‘ENDOTRACHEAL INTUBATION’)

Once advanced airway is secured give 1 breath every 6 seconds.

ADULT ALGORITH FOR MANAGEMENT OF CARDIAC ARREST

In brief:

• Shockable rhythm - ALWAYS Shock 

• Non- shockable rhythm – CPR with epinephrine (keeping approximately 4-minute interval between 2 epinephrine injections)

• Shock 🡪 CPR gain i.v. access + Inject Epinephrine 🡪Shock 🡪 CPR + Inject Amiodarone 🡪 Shock 🡪 CPR + Epinephrine 🡪 and so on...

• Time between 2 assessments/ 2 shocks/ time for which CPR is performed while injecting drugs = 2 mins

DEFIBRILLATION

For pediatric patients:

1st shock: 2-4 J/kg 

Subsequent 4J/kg (but not more than 10 J)

For adults:

Biphasic defibrillators: 100-120 J 

Monophasic defibrillators: 360 J

Placement of leads:

EPINEPHRINE:

1 mg 1:10000 i.v./ i.o. every 3-5 mins 

AMIODARONE:

1st Dose: 300 mg bolus dilute in 20-30 ml

2nd Dose: 150 mg bolus

VIDEO LINK:

ADVANCED CARDIAC LIFE SUPPORT (ACLS) ADULTS:

(2) ACLS Megacode - YouTube

Written by our guest authors - Hemant Kadam, Jignesh Bhadarka, Anveshi Nayan 

Illustrations by Anveshi Nayan and Devi Bavishi

#Ae(ONE)INTERN

 

Treatment of syphilis

What drug is used for the treatment of syphilis?

DWI-FLAIR Mismatch on MRI for Unclear-Onset Strokes

Diffusion-Weighted Image (DWI) and Fluid-Attenuated Inversion Recovery Image (FLAIR) Mismatch on MRI can be used as a surrogate for the time of stroke onset for unclear-onset strokes or "wake up" (nocturnal) strokes.

Why?

Cystinuria VS Cystinosis - know the difference!

 Hi!

Cystinuria is an AR disorder that is characterized by defective absorption of cysteine and other di-basic amino acids from PCT and intestinal lumen.

Cystinosis, on the other hand, is a lysosomal storage disease characterized by accumulation of amino acid cystine.

Note :

Cysteine + Cysteine = Cystine.

Fact :

Cystinosis is one of the most common cause of Fanconi's syndrome in pediatric age group.

Also, check hexagonal crystals seen in

That's all

- Jaskunwar Singh

Interview questions for the residency match

All frequently asked questions are highlighted with (FAQ)
How to approach each question is explained below it
Disclaimer: All these questions are compiled from different sources and personal experiences.

Genomic imprinting and Trinucleotide repeat -EXTRA EDGE

Hello Awesomites! 

1.Genomic imprinting IOC = methylation specific MLPA 

2.Trinucleotide repeat disorder = IOC is Trinucleotide primed PCR 

3.Fragile X Syndrome is XLR (mendelian inheritance) but once inherited during gametogenesis what happens is non - mendelian inheritance.

Confusing but thats the beauty. 

Can you tell me about Huntington disease what does mendelian and non mendelian inheritance mean? 

4.Angelman  that undergo whatever you learn (like maternal deletion and unipaternal disomy) involve chromosome 15 but gene is UBE3 ubiquitin protein. 

And praderwilli whatever you learn happens at chromosome 15 but gene is Sn RPN (small nuclear ribonucleoprotein polypeptide N)

 Hope it broadens your horizon.

-Dr.Upasana Y.