Wound Swab collection 

 

REQUIREMENTS: 

 ● Labelled sterile transport bottle/ test-tube (patient's details, site of the wound, date should be mentioned) 

● Swab and transport media

● Sterile normal saline 

● Antiseptic solution 

● Dressings 

PROCEDURE: 

 ● Follow universal precautions and aseptic precautions

PREPARATION OF WOUND: 

 ● For dirty contaminated wound before taking the swab, cleanse the wound thoroughly with sterile normal saline. A kidney tray can be placed below to collect the irrigating fluid

● Use sterile gauze to remove excess saline from wound surface

● If the wound is dry slightly moisten with sterile saline

● DO NOT USE ANY ANTIMICROBIAL CLEANSING SOLUTION BEFORE TAKING THE SWAB TO AVOID FALSE NEGATIVE REPORT

SWABBING: There are two methods for obtaining the swab:

● Levine method: for this 1 sq.cm area of viable wound bed tissue must be visible. Rotate the tip of the swab over 1 sq.cm area of viable tissue for 5 seconds. Use sufficient pressure to extract fluid from the wound tissue. If 1 sq.cm viable wound bed tissue is not visible then the swab cannot be collected. Debridement is required before swab can be collected. This technique is better then Z technique. 

● Z technique: move the swab in a zig-zag motion across the wound, while rotating the swab between the fingers.

DO NOT TOUCH THE WOUND EDGES AND PERIWOUND SKIN WITH THE SWAB

● Put the swab in the transport medium bottle/ empty sterile test-tube as indicated for microscopy, culture and sensitivity. 

● Remove the gloves, perform hand hygiene. Put on new sterile gloves

● Apply proper dressing over the wound

● Remove the gloves, perform hand hygiene 

● Fill the microbiology form with clinical details

● Send the sample and form to the laboratory as soon as possible.

 

VIDEO LINK: https://youtu.be/kte6RKorGis 

 

Written by our guest author Shrinivas Surnar

Illustrations by Ayushi Gupta

#Ae(ONE)INTERN 

 

Subcutaneous Anesthesia

Subcutaneous Anesthesia (Local Anesthesia)

 

REQUIREMENTS:

Appropriate consent for the procedure to be performed, betadine solution, spirit, 2 sterile needles (Blue 23 G and Purple 25G), 2 ml or 5 ml syringe, 2% lignocaine

PROCEDURE:

• Sterilize the incision site with betadine solution followed by spirit (or as indicated)

• Use blue needle for removing the anesthetic agent out of the bottle. Change the needle to the purple needle. Bend the needle used for injecting the anesthetic agent. (This technique is commonly followed so that we do not go very deep but it's not recommended because it increases risk of needle stick injury to healthcare providers) 

• Inject syringe loaded anesthetic agent subcutaneously at angle of 10-15 degrees, at planned incision site (or just lateral to wound), making sure the syringe bevel faces upwards

 

In case of a wound, the anesthetic may be given from the inside part of a clean wound after thorough cleaning of the wound so that we need not pierce the patient any more

• Aspirate to see that blood vessel has not been entered into

• Slowly inject the agent while withdrawing the needle simultaneously, noticing the rise in skin surface over the area of infiltration

Another method: 

Inject a small amount of anesthesia at the site of entry of needle before insertion of the whole needle inside the skin. Then, via the bleb created the needle is further advanced. This may slightly reduce the pain while injecting. 

 

VIDEO LINK:

https://www.youtube.com/watch?v=jDYwvn1AgU8

 

Written by our guest author Nitish Garg

Illustration by Ayushi Gupta

#Ae(ONE)INTERN 

 

Below Knee Amputation stump bandaging

Below Knee Amputation stump bandaging 

 

• Use an Elastic Bandage

 

• Start from Lateral Tibial condyle

• Bandaging diagonally across the stump to the medial distal corner

• Anchor with two fixing circular turns

• Continue with figure of 8 bandaging on BK stump

• Extend it upwards across knee and fix it above the knee joint at mid-thigh level with circular turns

VIDEO LINK: https://youtu.be/vYAg9sUcPaU

 

Written by our guest author Bhakti Vijaykumar Dongare

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN 

Above Knee Amputation stump bandaging

Above Knee Amputation stump bandaging

 

• With an elastic bandage, go around the waist to anchor it

       

• Extend it to the stump too

• Use another roll of elastic bandage, cover the stump

• Secure with two fixing circular turns

• Continue with figure of 8 bandaging

• Fix the bandage near the groin region.

 

VIDEO LINK: https://www.youtube.com/watch?v=M38bRIY5bhA  

 

Written by our guest author Bhakti Vijaykumar Dongare

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN 

Lipoma Excision

Lipoma Excision

 

REQUIREMENTS: 

Written Informed Consent, Sterile gauze pieces, Povidone-iodine, Ethanol, sterile plastic drape, Syringe with needle with local anaesthesia, Scalpel with no.15 blade, Artery forceps, Needle holder, toothed forceps, Babcock forceps, suture, Dressing material 

PROCEDURE:

• The skin is cleansed with povidone-iodine followed by spirit (or any alternate disinfectant) and the site is draped by a sterile plastic drape and a window is made in it.

 

• Local anaesthesia is obtained with 2% lidocaine with or without epinephrine. 

• Linear incision along Langer's line (vertically on the limbs and horizontally on the trunk) is performed with no. 15 blade until lipoma is visualized. 

• Artery is used to bluntly dissect around the lipoma to break all soft tissue connections (under and around it).

• Most lipomas require minimal dissection. Some chronic and multi-lobulated ones may require dissection. 

• Once separated, lipoma is expressed by digital pressure to the edges of the mass. Lipoma 'pops' out. 

• Babcock forceps may be used to provide traction to facilitate its removal. 

• Incision closed with simple interrupted sutures. 

• It is cleaned and sterile dressing is applied. 

• Advice to patient: Keep the wound dry. Alternate day dressing. Analgesics to be taken SOS. Antibiotics and Tetanus immunization when indicated. 

• Send the specimen for histopathological examination. 

PRACTICAL TIPS AND TRICKS : 

Incisions should be made with the belly of blade. 

VIDEO LINK https://www.youtube.com/watch?v=NYrMPOBYvg0&app=desktop&has_verified=1

 

Written by our guest authors - Shrishti Patil and Anveshi Nayan

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

Venepuncture (Blood collection)

 Venepuncture (Blood collection)

 

REQUIREMENTS: 

Cotton, ethanol, Syringe (size according to the amount of blood to be collected), needle (blue 23G or purple 24G), Vacutainers 

PROCEDURE: 

• Take verbal consent of patient. 

• Follow universal precautions. 

• Ask patient if blood had been collected recently. If yes, try to avoid that site. 

Contraindications of venepuncture from a particular site:

1) IV fluids being given to the patient at the same time 

2) local signs of infection 

3) Haematoma 

4) fistula (created for dialysis)

- Paralyzed is avoided 

• Hand of the patient should be supported. 

• Apply tourniquet (generally a glove is used to tie around the arm instead) and ask the patient to open and close the fist a few times (for congestion of vein). 

• Do not tap the veins. 

• Palpate for vein (For direction and course of vein).

 • Clean the area with cotton and alcohol in a circular motion from in-to-out without re-cleaning the area once it has been cleaned. 

• Do not re-palpate.

• Stretch the skin with non-dominant hand and pierce the skin with the needle (with bevelled end facing up) at an angle of 20 degree. 

• Aspirate the blood into the syringe.  

• Before removing the needle, untie the tourniquet (it helps to reduce the blood loss after retracting the needle)

• Remove the site. 

• Recap needle while putting pressure with the help of cotton swab on it by placing the cap on a surface and then insert needle attached to syringe inside the cap (Recapping is generally not advisable but commonly practised). 

• After capping it properly, remove the needle along with its cap. 

• Then push the blood from the syringe into prelabelled vacutainers by removing their covers. 

• Thank the patient for cooperation.

To collect venous blood for venous blood gas analysis, when heparin isn't available, do the following:
1) Collect blood in green vacutainer

2)Attach a new needle to the syringe

3)Aspirate blood from the vacutainer

FOR BLOOD CULTURE: 8-10ml blood is drawn into the syringe through a sterile needle and then pushed out into a blood  culture bottle containing the transport medium. 

The specimen is refrigerated immediately (although immediate transport of specimen to laboratory is preferred.) 

VIDEO LINK:

https://youtu.be/6tXpN086N6A

 

Written by our guest author - Abhishek Ganacharya

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

 

Lumbar Puncture

Lumbar Puncture

REQUIREMENTS:

Written Informed Consent, Gloves, Skin prep and Drape, Local anaesthesia kit, 20 or 22G styletted spinal needle, Collection tubes

PROCEDURE:

• Follow universal precautions and explain the procedure to the patient.

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

• Antiseptic is applied at the puncture site from centre to outwards. 

• Local anaesthesia 2% lignocaine given (without epinephrine to avoid cord infarction). 

• A needle with stylet directed 10-15° cephalad, pointing towards patient's umbilicus (because spinous processes are directed downwards from the spine) 

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

 

• Keep the bevelled end up and in the midline.

• As soon as the dura is pierced a pop-up sensation or sudden loss of resistance is felt. 

• Withdraw stylet gradually. 

• CSF collection CSF comes out drop by drop. Collect it in 4 different sterile tubes for biochemical, microbiological, cytological and other tests respectively.

• After the procedure, insert the needle back in the cannula, withdraw the entire assembly. Apply a gauze, put a tight dynaplast. 

Ask the patient to be in supine position for 10-15 minutes. 

TIPS & TRICKS :

Before the antiseptic solution, there is a technique to mark the exact point of the LP. Identify the iliac crest, come medially→Mark/Indent the skin with the back of the needle cover→ then sterilize. 

After sterilizing, you can't palpate the iliac crest because that part is not sterile. 

So, either wear 2 pair of sterile gloves with sterile technique or wear 1 pair→do the sterilizing bit→then wear another pair. (don't touch the stylet with unsterile gloves) 

PROBLEMS FACED: 

1)

If the CSF still doesn't come, ask a  senior. Patient's BP may be low. If so,  give one pint normal saline, full flow after. Keep the needle at the same place (do not remove the needle), repeat the procedure after 10 minutes.

2)

If blood clots in the needle, use another needle. 

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

4) When you hit a bone, go down then sideways. While manipulating, especially while coming out, do it by slightly rotating the needle, and stopping briefly. Don't directly pull it. 

5) Guarded LP: when the CSF flow is very fast 

 

VIDEO LINK: https://youtu.be/CKLpIDhuJrE

 

Written by our guest author - Aakib Sohil Ghori
Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

Trail's Sign

Shift of trachea produces prominence of sternal head of sternocleidomastoid on the side to which the trachea is shifted. It is called Trail's sign.

The pretracheal fascia encloses the clavicular head of stemomastoids muscle on both sides. When the trachea is shifted to one side, the pretracheal fascia covering the stemomastoid muscle on that side relaxes, producing the clavicular head more prominent on the side of tracheal deviation.

Endotracheal intubation

 

ENDOTRACHEAL INTUBATION

REQUIREMENTS:

Gloves, face shield, suction, Laryngoscope and blade, Endotracheal tube (of required size) with stylet, bag and mask apparatus, 10 cc syringe for checking air leak, oral or nasal airway, tape for holding the tube

PROCEDURE:

1. Check the equipment before starting the procedure- if the light on the laryngoscope is functioning and check the ET tube for air leaks by filling it up with 10cc air (the balloon should be tense) Insert the stylet in the ET tube to give it proper form. Make sure the stylet doesn’t protrude outside the tube.

2. Position the patient in the “sniffing” position- flexion at the neck and extension at the head.

3. Place a pillow or towel roll under the occiput to elevate it. (It aligns the 3 axes- pharyngeal, laryngeal and oral to facilitate better visualisation of the vocal cords.)

    

   

4. Pre-oxygenate if possible (1-3 min 100% Oxygen)

5. Stand behind the head of the patient. The head of the patient should be at the lower end of your sternum. Open mouth and inspect: remove any dentures/debris, suction any secretions.

6. Check for proper sedation by the laxity of jaw.

7. Hold the handle in your left hand (non-dominant hand), blade down, pointing away from you. 

8. Retract the lips with your right hand. 

9. Insert the laryngoscope blade to the right of patient’s tongue. Gradually move the blade towards the centre of the mouth pushing the tongue to the left.

10. Advance the laryngoscope gradually to visualize the epiglottis. 

11. If MacIntosh- Place the tip of the blade into the vallecula between the base of the tongue and the epiglottis and lift anteriorly to expose the vocal cords.

If Millers- Place the tip of the blade just past the epiglottis and lift anteriorly to expose the vocal cords.

THE LIFT- When the tip of blade is properly positioned lift the laryngoscope upwards and forwards/away at a 45-degree angle. Direct the force of your lift along the axis of the laryngoscope handle in direction of the ceiling over the patient’s feet.

12. Hold the preselected tube in your right hand like a pencil, curve forward. Pass the tube to the right of the blade, past the right side of the tongue. The tube should not obstruct the view of the vocal cords.

13. Pass the tube through the vocal cords until the balloon disappears into the trachea. Remove the stylet and advance the tube until the balloon is 3-4cm beyond the vocal cords. The marking of the tube at the incisors will show 21-24cm when tube is in position 

14. Remove the laryngoscope and inflate the balloon with 10cc air to prevent air leaking during ventilation. Attach the tube to bag and mask apparatus and ventilate.

15. Place the end tidal CO2 detector. Colour change will be seen within first 6 breaths.

16. Confirm the position of the tube by auscultating over the lungs and epigastrium. Listen for the presence and equality of breath sounds over both lung fields and for the absence of gurgling sounds over the stomach. (to check for accidental oesophageal intubation)

17. If not in correct position deflate the cuff and remove the tube resort to Bag and Mask Ventilation, repeat the intubation process from the beginning. If the tube is in too far, the right lung will be ventilated only by the right main bronchus (decreased left lung breath sounds). Deflate the cuff and withdraw the tube 2-3 cm re-inflate the tube and recheck the position (symmetrical breath sounds)

18. When the tube position is confirmed, tie it in place with cotton tape and attach it to the ventilating apparatus.

PRACTICAL TIPS AND TRICKS

• When inserting the stylet give the ET tube a form of a “hockey stick”- 30-35-degree angle anterior before the balloon. If it’s too straight it risks oesophageal intubation and if too angled will get hung up on the vocal cords.

   

• Grasp laryngoscope firmly but don’t clench your fist because this decreases control and causes early fatigue.

   

• Wrist must remain rigid during laryngoscopy.

   

• Keep your elbows in. Lift on a line connecting the patient’s head with the intersection of the opposite ceiling and the wall. It won’t be straight, but keeping your arm straighter and fairly rigid it gives you the strength of your shoulders to lift the head. It prevents you from using the teeth as a fulcrum — dangerous for the teeth. And it allows you to use binocular vision for depth perception.

   

• With your shoulders relaxed and your arms by your sides you can lift the jaw easily without rotating the blade back onto the teeth.

   

• If vocal cords are not visualised- Perform the “Sellecks Manoeuvre” -apply cricoid pressure, make your assistant place their thumb on one side of the cricoid ring and their index or ring finger on the other. Pushing down firmly to force the cricoid forces the vocal cords downward and often into the field of view. It also compresses the oesophagus between the cricoid cartilage and the cervical vertebrae and prevents passive regurgitation of gastric contents.

• Pass the tube into the larynx through the cords in one smooth motion. If the patient is breathing, time the forward thrust for inspiration when the cords are fully open. During expiration, the tube may bounce off the closing cords into the oesophagus.

 

REFERENCE LINKS:

1)NEJM link (Similar to steps written; 11:50 min video)

https://www.youtube.com/watch?v=t6q9Bys7QDk

2) https://www.youtube.com/watch?v=z6HMY9dhh2c (2:21 minute video)

 

Written by our guest author: Chitra Wadekar

Illustrations by Devi Bavishi

#Ae(ONE)INTERN

 

 

Nasogastric tube insertion

 

NASOGASTRIC TUBE INSERTION

REQUIREMENTS:

Verbal consent, Gloves, Fine bore nasogastric tube (feeding only) or nasogastric “Ryles” tube 16Fr (all other indications), lubricant, Syringe, Securing device (sticking), Cup of water (may be required) 

PROCEDURE:

• Ask the patient to breathe in through each nostril separately to judge which is more patent.

• For this procedure the patient should be positioned on the bed upright and facing forward (sniffing position). Put on your gloves.

• Lubricate the tip of the tube and begin to insert through one of the nostrils keeping the tube posteriorly parallel to the floor of the nose. If any resistance is encountered change to the other nostril.

• Once nasopharynx is reached, ask the patient to flex their head and swallow water/ saliva.

• As they swallow advance the tube to the desired length.

• At the end of the procedure, air filled syringe is attached and air is pushed in while auscultating at the epigastrium.

• A swoosh/ pop sound confirms the location of tube in the stomach.

• Fix the tube in place using sticking.

                       

• NOTE:

If the tube enters larynx the patient may gag or cough. Pause for a moment, withdraw slightly, ease the patient and then continue inserting it again.

For patients in supine position, slightly flex their neck while inserting the tube.

For unconscious patients, intubation in lateral decubitus has a higher success rate according to a pubmed article (https://pubmed.ncbi.nlm.nih.gov/28544238/).

PRACTICAL TIPS AND TRICKS:

1) A gentle curve can be created in the Ryle’s tube by winding it around our finger before insertion. Then while inserting the tube, let that slight curve point down.

VIDEO LINK:

https://youtu.be/1OakmxZDa5c 

 

Written by our guest authors: Ashish Gaikwad and Anveshi Nayan

Illustration by Anveshi Nayan

#Ae(ONE)INTERN