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

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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. 

Essential tremor - a mnemonic.

Do you often forget the features of 'essential tremor'? Well shake no more, 'coz here's a mnemonic that will straighten things up for ya!

Causes of Hypoglycemia | Mnemonic

NEXUS criteria for Cervical Spine imaging - Mnemonic

 NEXUS criteria for Cervical Spine imaging 

Any 1 of the following is an indication : 

Mnemonic =  “NSAID”

Riley- Day Syndrome mnemonic

 

Shy-Drager syndrome mnemonic

 

Weber & Rinne test mnemonic / trick

Fetal heart rate tracing | Mnemonics, Concepts & Management | High yield...

Algorithm 7 : Hypocalcemia management

Algorithm 6 : Thyroid Nodule

Mnemonic for Postoperative fever | Causes with timeline

Algorithm 5 : Management of Posterior hip dislocation

Ear Syringing

EAR IRRIGATION (SYRINGING)

REQUIREMENTS:   Water (temperature being as close to body temperature as possible), kidney tray, Simpson’s aural syringe/ 50 ml syringe attached to 16-18 gauze needle or pulsating water device, towel (if available)

PROCEDURE: 

• Examine the ear. 

(Do not irrigate if there is: severe pain, recent trauma or surgery or a dry perforation of tympanic membrane, inability of patient to sit upright, organic foreign body in the ear, opening into mastoid, severe otitis externa, history of middle ear disease, ear surgery, inner ear problems [vertigo] or radiation in the area) 

• Ask patient to sit upright. 

• Hold the pinna backwards and upwards in adults and backwards in children to straighten the ear canal.

• Keep a towel on the shoulder. 

• Use a kidney dish to catch solution.

• While irrigating direct the syringe towards the ear canal, postero-superiorly.  

  
  
  
  

• Apply firm and constant pressure to the syringe.

• Dry mop the ear and check it again to see if everything is out.  

  

Written by our guest author - Abhineet Desai

Illustration by Devi Bavishi

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Contraception

 CONTRACEPTION 

Cu-T INSERTION 

REQUIREMENTS:  

Written Informed consent, IUD, Povidone Iodine, Spirit and drapes, Sims’s speculum, Allis forceps, Uterine Sound 

 

PROCEDURE: 

• Begin with the history and clinical examination to rule out contraindications. 

• Before inserting the IUD, always do UPT to rule out pregnancy. 

• The patient is taken up in the OT (but can be done in OPD or labour ward immediately post-partum). An anaesthetist should be present if in case perforation occurs. 

• POSITION: Standard lithotomy position with legs in stirrups. 

• Scrubbing, painting, and draping should be done. 

• Bimanual examination to check for uterine size, position, version, and adnexal pathology. 

• Depress posterior vaginal wall with Sim’s speculum and hold the anterior lip of cervix using Allis forceps. 

• Using uterine sound, measure utero-cervix length and the accordingly adjust the bobbin. 

• The technique used is “No Touch/ Withdrawal technique”. 

• CuT is self-loaded. Remove the whole thing without touching CuT. 

• Plunger should not touch the vaginal wall. Reach upto the uterine fundus. Pull the ring behind on the plunger. CuT is unfolded. 

• Slowly remove the loader so as not to disturb the CuT. 

• Cut the tail (2.5-3 cm). The patient should be made to feel the tail. 

• Observe for about half an hour for uterine cramps (since foreign body inserted so uterus tries to expel it)  

Managed by giving Drotaverine/Dicyclomine. 

 

• Record the date of insertion. Document it on CuT card and mention the date of expiry. Give it to the patient. 

• Counsel the patient regarding all the possible complications and also regarding the follow-ups. 

 

ANTARA 

Injectable Contraceptive DMPA (Under ANTARA programme) given as i.m. injection on outer upper quadrant of buttock. 

Dose: 150 mg every 3 months  

Written by our guest author - Ayushi Gupta

Illustration by Devi Bavishi

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Central Venous Catheterisation

CENTRAL VENOUS CATHETERISATION

 

Internal jugular vein approach (Seldinger's technique)

Position of patient 

Patient should be in head low position with head turned to face the left.

Procedure 

1. Skin is cleaned with antiseptic. Neck can be extended by keeping a rolled towel or normal saline bag under shoulder.

2. Local anaesthesia may be infiltered but that causes a wheal production which may hide the puncture site.

3. Right internal carotid artery is palpated lateral to cricoid cartilage. 

4. Triangle formed by two heads of sternocleidomastoid muscle and clavicle is located.  

5. The heparinised needle with the syringe attached is inserted starting at the apex of the triangle keeping fingers gently over the internal carotid artery just lateral the pulsations at an angle 30 to 40 degree to the skin and advancing it downward in the direction of nipple on same side. 

Another way to gain access to IJV is to go behind the posterior head of sternocleidomastoid. 

6. Blood is aspirated to confirm that needle is in the lumen of vein.

7. The guide wire is threaded through needle into vein with J shaped end first.

8. Needle is then removed.

9. Dilator is passed over guide wire in the twisting motion to dilate the site of skin puncture. A small incision in the skin may be necessary to introduce the dilator.
   
   
   

10. Dilator is removed and catheter is passed over guide wire.  

11. Guide wire is removed. 

    

12. After confirming blood can be aspirated freely the catheter is flushed properly with heparinised saline.

    

13. The catheter is secured in place with suture and sterile dressing is given. 

 

    •     Post procedure X ray Chest is taken for confirming the position of the central line 

For accurate CVP measurement, the tip of the central venous catheter (CVC) should lie within the superior vein cava (SVC), above its junction with the right atrium and parallel to the vessel walls.

Other Sites  

1. Subclavian Vein 

2. Antecubital Vein 

3. Femoral Vein 

Written by our guest author - Akash Davhale

Illustrations by Devi Bavishi

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Arterial Puncture

ARTERIAL PUNCTURE (ABG ANALYSIS)

REQUIREMENTS:

Verbal consent, Gauge Piece, Syringe, 23G needle (for radial or brachial artery) OR 21-22G needle (for femoral artery), Sterile gloves, Antiseptic skin solution (generally ethanol is used), cotton, sterile gauze piece

Lithium heparin - 1-2 mL lithium heparin (1000 U/mL) should be aspirated into the syringe through another sterile needle and then pushed out; the plunger should be left depressed to allow the arterial blood flow to fill up the syringe. 

For arterial 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

4) Remove any air bubbles

PROCEDURE:

• Take all aseptic precautions. 
• First do Allen’s Test if planning to do a radial artery puncture to assess collateral circulation.

i. Firm occlusive pressure is held on both the radial artery and the ulnar artery  

ii. (see the first image below).The patient is asked to make a fist and open it, repeatedly till the palmar skin is blanched (see the second image below). Overextension of the hand or wide spreading of the fingers should be avoided, because it may cause false-normal results. The pressure on the ulnar artery is released while occlusion of the radial artery is maintained (see the third image below). The time required for palmar capillary refill is noted. (It should be ≤7 seconds normally).

 

• Attach the heparinised syringe attached to another sterile 23G needle
• Palpate the location of radial Artery
• Wrist should be positioned in extension

• Clean the puncture site for 30 sec
• Warn the patient for sharp scratch
• Insert the needle at 30- 45°
• Aim towards maximum point if pulsation. Draw the plunger up once blood is seen in the syringe.

• Remove the needle. 
• Ask the relative or patient to continue to apply firm pressure over the puncture site for 5 minutes (to ensure haemostasis)
• Recap the needle (not advisable because of the risk of needle-stick injury but done because special ABG syringes and needles are generally not available). For recapping, place the cap of needle over a surface like bed or table and then insert the needle inside the cap. DO NOT pick up the cover of needle to recap it (to prevent needle-stick injury). 

**When in doubt if you have had a needle prick or not, remove your gloves and fill it with water and look for any leak. If present, it is likely that you have had a needle prick.

CONTRAINDICATIONS:

• An abnormal Allen test: Consider attempting to puncture at a different site. 
• Local infection or distorted anatomy at the potential puncture site (eg, from previous surgical interventions, congenital or acquired malformations, or burns). 
• The presence of arteriovenous fistulas or vascular grafts, in which case arterial vascular puncture should not be attempted. 
• Known or suspected severe peripheral vascular disease of the limb involved. 
• Severe coagulopathy
• Anticoagulation therapy with warfarin, heparin and derivatives, direct thrombin inhibitors, or factor X inhibitors; aspirin is not a contraindication for arterial vascular sampling in most cases 
• Use of thrombolytic agents, such as streptokinase or tissue plasminogen activator. 

COMMON SITES FOR ARTERIAL PUNCTURE: 

• ABG sampling is usually performed on the radial artery because the superficial anatomic presentation of this vessel makes it easily accessible. 
• Other sites include: femoral or brachial artery (present medial to tendon of biceps brachii).

PRACTICAL TIPS & TRICKS:

• If arterial blood flow is not obtained, the operator might slowly pull back the needle; it is possible that the needle has gone through the vessel 
• Initial arterial flow may subsequently be lost if the needle moves outside the vessel lumen; reidentification of the arterial pulse, using the nondominant middle and index finger, and repositioning the needle in the direction of the vessel could be attempted; avoid blind movement of the needle while it is inserted deeply in the patient’s body—pull it back to a point just below the skin, and redirect it to the arterial pulse felt with the other hand 
• Puncture of venous structures can be identified by lack of pulsatile flow or dark-coloured blood, though arterial blood in severely hypoxemic patients can also have a dark appearance; if venous blood is obtained, removal of the needle from the patient might be necessary to expel the venous blood from the syringe
• Excessive skin and abundant soft tissue may obstruct the puncture site; the operator can use the nondominant hand to smooth the skin, or an assistant can remove the subcutaneous tissue from the puncture site field 
• Incomplete dismissal of heparin solution from the syringe could cause falsely low values for the partial pressure of CO; to avoid this, the operator should expel all heparin solution from the syringe before arterial puncture 
• Incomplete removal of air bubbles can cause falsely elevated values for the partial pressure of oxygen; to avoid this, the operator should be sure to completely remove air bubbles from the syringe (vented plungers have an advantage over standard syringes in this regard)
• Avoid puncture of the brachial artery or femoral artery in patients with diminished or absent distal pulses; the absence of distal pulses may signal severe peripheral vascular disease.

Written by our guest author - ABHISHEK GANACHARYA

Illustrations by Devi Bavishi

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Automated Perimetry

 HUMPHREY FIELD ANALYSER (HFA)

1.Perimetry should be performed in a distraction-free environment, to enable the patient to concentrate on the perimetric test.

2.The perimeter is automatically calibrated each time it is turned on. Ideally, patient data (date of birth, refraction, etc.) are entered before the patient enters the room.

3.Before putting the patient onto the machine, the requirements of the test itself are clearly explained and the patient is instructed as follows.

4. Before fully positioning the patient, the eye not being tested should be covered with an eye patch that allows the patient to blink freely.

INSTRUCTIONS TO PATIENT

• Perimetry tests your central and peripheral vision

• Be relatively still once positioned

• Always look straight ahead at the fixation target. Do not look around the bow for stimuli.

• Press the response button whenever you see the stimulus 

• The stimulus in a flash of light

• Only one stimulus is presented at a time

• The stimulus might appear from anywhere. Some stimuli are very bright. Some are very dim and sometimes no stimulus is presented. You are not expected to see all stimuli

• Do not worry about making mistakes

• Blink regularly to avoid discomfort. Don't worry about missing a point the device does not a measure while you blink

• If you feel uncomfortable or are tired close your eye for a moment the test will automatically stop. The test will resume once you open your eye.

• If you have a question, keep the response button pressed this will pause the test

5. The patient is positioned appropriately and comfortably against the forehead rest and chin rest. The lens holder should be as close as possible to the patient’s eye to prevent artefacts. 

6.The Analyser projects a series of white light stimuli of varying intensities (brightness), throughout a uniformly illuminated bowl.

 

 

7.The patient uses a handheld button that they press to indicate when they see a light. This assesses the retina's ability to detect a stimulus at specific points within the visual field. This is called retinal sensitivity and is recorded in 'decibels' (dB).

 

 

8.The Analyser currently utilises the Swedish Interactive Thresholding Algorithm (SITA); a complex mathematical formula which allows the fastest and most accurate visual field assessment to date.

For more information, see the youtube video (link below)

 https://youtu.be/TqL5KvvYJu4 

Written by our guest author - Jignesh Bhadarka

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