Nebulization

 

NEBULIZATION  

Nebulization can be delivered by a face mask or a mouth-piece. 

 PROCEDURE: 

• Take all the aseptic precautions. 

• Clean the mask with spirit. 

 

• Add the measured amount of drug into medicine cup/ mixing chamber. 

(In neonates we usually give hypertonic saline for nebulization) 

• Setup all the connections i.e:  

1. Mask with the mixing chamber/ medicine cup 

2. One end of air tube to outlet of the machine/ pipe 

3. The other end of air tube with mixing chamber and mask 

 

 

 

• Switch on the machine. 

• Look whether fine mist is coming out through the mask. 

• Place child in comfortable position (Head Upright), or in Mothers lap.

• Put the mask to the face of child covering nose and mouth adequately. 

  Instruct the child to breathe in and out comfortably. 

  
   

• Continue nebulization until fine mist is no longer present. 

• Instruct the child to gargle or rinsing of mouth. 

• Clean the machine after use with spirit and place it back in sterile/ clean pack. 

  REFERENCE VIDEO LINK: 

   https://www.youtube.com/watch?v=qK-RqSg566c&feature=youtu.be 

   

Written by our guest author: Manpreet Kaur

Illustrations by Anveshi Nayan

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Spinal Anesthesia

Spinal Anesthesia

REQUIREMENTS:

Gloves, Povidone iodine, Spirit, Drape, Local anaesthesia kit, 18G needle, 25G dura splitting spinal needle, Bupivacaine/fentanyl/Lignocaine 

PROCEDURE:

PREPARATION: Clean skin of back with povidone-iodine followed by alcohol and

drape the back of patient.

POSITION: Given so as to increase the distance between two spinous processes.

SITE: It is given in midline @ L3-L4 or L4-L5 level (horizontal line passing between the 2 iliac crests passes through L4 spinous process)

PROJECTION & PUNCTURE:

• Local anesthesia should be injected at the site.

• An 18 G introducer directed 10-15 degree cephalad (because spinous processes are directed downwards from the spine) up to interspinous ligament is introduced and stabilized with one hand.

• With the other hand, a 25 G dura splitting spinal needle (with stylet) is then passed through the introducer till subarachnoid space is entered (recognized by 2nd 'loss of resistance' feeling).

• NOTE: Introducer may not be required for thin needles like 25G needle.

• Stylet is then removed and CSF appears at the hub.

• Syringe with local anesthestic is then attached to the spinal needle while

holding it stable.

• Aspirate to see free flow of CSF and then inject the drug.

 

DRUGS USED COMMONLY : Bupivacaine, Lignocaine, Fentanyl 

LEVEL OF ANAESTHESIA : Checked by pinching skin by forceps

PROBLEMS  FACED:

1)

If still no CSF appears, ask a senior.

2)

If blood clots in the needle, use another needle. 

3) If patient complains of sudden shooting pain in one leg (due to nerve injury by needle), move the needle medially.

VIDEO LINK:

https://youtu.be/c_tLaZQoOt4 

 

Written by our guest authors: Krishna Borse and Anveshi Nayan

Illustrations by Anveshi Nayan and Ayushi Gupta

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Distal Radius Fracture Reduction

Distal Radius Fracture Reduction 

 

1. Get X-RAY WRIST AP and Lateral View 

    

   

2. ANAESTHESIA- (Sometimes people don’t give any anaesthesia, which should be avoided)

2 Options: 

A. Hematoma Block 

-Locate fracture site
-Under sterile prepration using 20G needle Pierce and go deep
-Pull back to confirm fracture site (you will get blood)
-Inject 5-6 cc 1% lidocaine
-Wait for 10-15 min

 

B. Sedation

 

3)REDUCTION FOR COLLES

• Hold the hand of patient as if "shaking hand". Dis-impaction of fragment: (by traction and counter-traction) 

• Palmar flexion and ulnar deviation pronation (see pic) 

(it may be necessary sometimes to accentuate the fracture while applying traction to free the fragments before pushing it into place) 

 

 

4)CAST is applied with moulding (contrary to normal rule of immobilizing one joint proximal and one joint distal, the elbow joint is spared here as generally the patients are elderly) 

(while applying cast continuous traction is given by the assistant by pulling from finger) 

 Three-point moulding of cast

-1 hand at fracture site
-Other distal to fracture site on opposite side of wrist
-Assistant hand is applied at elbow

5) X-RAY to confirm the reduction and correction of dorsal and lateral tilt 

Repeat x-ray every week for first 3 weeks to detect re-displacement.

 

Written by our guest author -Pratik Mundada
Illustration by Devi Bavishi
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Cytomegalovirus mononucleosis signs/symptoms/clinical manifestations

 CMV mononucleosis signs/symptoms/clinical manifestations

I thought of turning it into a mnemonic! ABCDEFGH...

Timeline for USMLE for IMGs

BEST WAY TO PLAN YOUR USMLE JOURNEY

• September 1st of every year is when ERAS starts accepting applications. The deadline usually is September 15th (except Match 2021 where it was Oct 21st and Match 2022 where it is Sept 29th)

• This means you need to have all your documents and scores ready before September 15th.

• ECFMG certification: This takes anytime between 7 days to 3-4 weeks to arrive from the day you apply for it.
  1. When can you apply for ECFMG certification: When you have all your step 1, 2 CK, and OET scores in hand + You have graduated medical school and your credentials are verified.
  2. Credential verification: Your medical school needs to send your degree and final transcript to ECFMG. This process can take between 1-4 weeks.
  3. There is usually a delay in score reporting that happens for Step 1 and Step 2 CK around May-June every year. Be on the lookout for that and plan accordingly. If there is no delay, your Step scores should come within 3-4 weeks of taking the test. 

Crescent-shaped gametocytes in P. falciparum malaria

The most definitive finding of P. falciparum that can be seen in a blood smear when viewed under a microscope is the shape of the gametocytes.

Here is my mnemonic for it.

Urinary Catheterisation

 URINARY FOLEY’S CATHETERISATION

• Wash hands and wear sterile gloves.

• Ask someone to put lignocaine jelly at the back of your left palm.

 

 

 

• Don’t touch any sterile field with your left hand.

• As the bulb of the penis is reached it should be gently rotated down in line with the patient’s body and catheter should be further advanced till the Y of catheter is at the level of urethral meatus.

• Wait for urine to drain.

 If no urine is draining:

a) Gently press supra-pubic region)

b) Aspirate via the urobag port using a sterile syringe.

c) Disconnect and reconnect the urobag and foley's catheter.

• After visualization of urine return, inflate the distal balloon by injecting 20-30 ml of normal saline through the cuff inflation port. (Distilled water is preferred).

• Gently withdraw the catheter from the urethra until resistance is met (else excessive intravesical length of foley’s can cause it’s knotting and failure of removal).

• Reduce the foreskin (else paraphimosis can occur).

 

*For females, do not insert the whole length of foley’s as female urethral length is only around 4 cm.

• Keep the catheter and collecting tube free from kinking.

• Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

 

URINE SAMPLE COLLECTION FROM A CATHETERISED PATIENT

I) If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), clamp the catheter for sometime so that urine is collected in the catheter tube.

Disinfect the site of collection.

Remove the clamp

II) Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag.

 

URETHRAL CATHETER REMOVAL

Use a syringe to empty the balloon, and then apply gentle traction. 

 

Written by our guest author - Anveshi Nayan

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

 

Suture and Staples removal

SUTURE/ STAPLES REMOVAL

• IN MOST CASES, sutures and staples applied to surgical wounds are removed in 7 to 10 days.

• Inform patient that they might feel slight discomfort, such as a pulling sensation or stinging.

• Wear clean gloves and remove the dressing.

• Inspect the wound for edge approximation and signs of infection 

1. If after the longest adequate time, wound hasn’t approximated, it means it never will until underlying cause for the same is treated and so, sutures are removed nevertheless.

2. Serous discharge from a wound is generally not problematic

• Remove the gloves, wash your hands, and put on sterile gloves. 

• Clean the suture line with an antimicrobial solution before and after suture or staple removal.

• Always first remove alternate sutures/ staples. Assess the wound for dehiscence; if none occurs, remove the remaining sutures.

To remove a plain interrupted suture

REQUIREMENTS: Sterile gauze piece, Ethanol, Blade and Forceps

•  

  
  

• Gently grasp the knot with forceps (by your non-dominant hand) and raise it slightly.  

  Place the curved tip of the suture scissors/ blade (in dominant hand) directly under the knot as close as possible to the skin 

• Gently cut the suture and pull it out with the forceps with the direction of pull being ‘over’ the wound rather than ‘away’ from the wound (to prevent any tension on the wound).

  
  

  

• Forceps may not be available (not recommended but it may sometimes be the case) so hold the knot up with one hand and cut the suture directing the force such that the sharp edge faces away from your other hand (to prevent injury to self).

To remove staples

REQUIREMENTS: Staple remover, Sterile gauze piece, Ethanol

• Place the lower jaw of the remover under a staple. Squeeze the handles by depressing your thumb completely to close the device. This bends the staple in the middle and pulls the edges out of the skin.

  
  

  
  
  

  
  

  
  

• Do not pull up the staple removal device.

• Gently move the staple away from the incision site when both ends are visible. Hold the staple remover over a gauze piece or sharps container relax pressure on the handles, and let the staple drop into the container.

After suture or staple removal

• Count the number of sutures/ staples removed and re-confirm with patient (to ensure none is left).

• Apply sterile wound strips to prevent dehiscence. 

NOTE:

• If dehiscence occurs, cover the wound with sterile gauze saturated with sterile 0.9% sodium chloride solution and immediately notify a senior.

• Don’t remove remaining sutures or staples if dehiscence occurs.

   

  REFERENCE VIDEO LINKS:

• Removal of plain interrupted suture: https://youtu.be/Hg-bSb1FLTA 

• Removal of surgical staples: https://youtu.be/OatwWz1k2s8 (** DO NOT HOLD THE REMOVED STAPLES IN YOUR HAND)

Written by our guest authors - Anveshi Nayan and Neha Kumari

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN