Clerks Companion Handout Internal Medicine PDF

CLERK COMPANION HANDOUT | INTERNAL MEDICINE TIP: One of the most prominent veins is the ‘Clerk’s vein’, a tributary of the cephalic vei...

CLERK COMPANION HANDOUT | INTERNAL MEDICINE TIP: One of the most prominent veins is the ‘Clerk’s vein’, a tributary of the cephalic vein located at the lateral aspect of the wrist near the anatomic snuffbox, although location is not ideal due to joint movement INTERNAL MEDICINE CONTENTS Page Peripheral Venous Line Placement 1 Central venous Line Placement 2 ECG Interpretation 2 Thoracentesis 5 Paracentesis 6 Intubation 6 o Lower extremities: Dorsal metatarsal veins, draining to Insertion of Nasogastric Tube 7 the dorsal venous arch, medially to the great saphenous Basic Fluid Management 7 How to Admit a Patient 8 vein, laterally to the small saphenous vein “Most Common” in Internal Medicine 8 I. PERIPHERAL VENOUS LINE PLACEMENT Convenient and immediate access for IV administration of fluids, medications, blood products, and/or nutritional support. Indication/s: o Administration of fluids, medications, blood products, and/or nutritional support. § Site of blood collection prior to administering IV fluids/medications Contraindications: o No absolute contraindications o Relative contraindications: § Local infections and burns on the intended site of Steps insertion 1. Prepare all materials (IV Cannula/s, gloves, § Arteriovenous fistula formation or deep vein tourniquet, sterile cotton, medical adhesive thrombosis on the affected limb tape/dressings, sharps disposal, IV Fluid/Medications Non-dominant upper extremity – usually used for to be administered, saline flush) convenience of the patient, less risk of 2. Practice universal precaution. Perform hand hygiene extravasation/dislodgement as the extremity is less used and use gloves. Potential sites: 3. Locate your target vein (ideally the most prominent, o Start distally and look for straight, nonbranched veins. straight, nonbranching, distal vein) o Upper extremities: Dorsal metacarpal veins at the o Techniques on how to locate your target vein: dorsum of the hand, draining to the dorsal venous arch, § Apply tourniquet proximal to the target area to into the lateral cephalic and medial basilic vein, with the engorge distal veins median cubital vein § Instruct the patient to repeatedly open then close hand § Rubbing/warming the skin around the target area 4. Apply tourniquet proximal to the site 5. Clean area with antiseptic, cleaning in circular motion inside to out FOCUS REVIEW CENTER | Focus Review Center | [email protected] | focusreviewcenter.com 1 CLERK COMPANION HANDOUT | INTERNAL MEDICINE 6. Stabilize vein by applying traction to skin using your anesthetic - Lidocaine 1%, Scalpel – blade II, nondominant hand Central line kit, Fr 6 to 8 catheter and dilator, 7. Holding the cannula, have your index and middle Guidewire, Syringes, Needles 18- and 22- gauge, finger on each wing, and your thumb at the flashback and polypropylene suture 4-0) chamber, orient your hand to a comfortable position 2. Place patient in Trendelenburg position, head facing with the needle pointing proximally to the target vein the contralateral side of insertion site 8. With the bevel facing up, insert the needle at a 45 3. Locate target vein using an ultrasound or the degree angle aiming towards the vein and slowly landmarks: between the clavicular and sternal advance until a flashback of blood appears in the heads of the sternocleidomastoid (SCM) muscle at chamber. the base of the neck 9. Slightly decrease the angle and carefully advance 4. Observe strict aseptic technique (proper through the vein, following the contour, until the handwashing, gowning, draping, sterile preparation bushing is on the insertion site. of access site) 10. Using your nondominant hand, apply pressure 5. Infiltrate the skin with 1% Lidocaine around the proximal to the insertion as you carefully retract the insertion site needle with your dominant hand. 6. Insert 18-gauge introducer needle at a 45 degree at 11. Discard the needle properly the apex formed by the two heads of the SCM. 12. At this point, you may collect blood directly from the o You may opt to insert the needle, guided hub, attach the IV administration set, or attach a with a sterile bedside ultrasound or follow heplock/Luer lock onto the hub the landmarks 13. Remove the tourniquet 7. Advance the needle lateral to the carotid pulsation, 14. Secure the cannula onto the skin using medical directed towards the ipsilateral nipple, while adhesive tape/dressing aspirating. 15. To confirm if the access is in the vessel, a saline push 8. Once venous blood is aspirated, remove the syringe or the attached IV fluid is administered to ensure and thread the guidewire through the introducer into adequate flow, observing for swelling or counter the vessel up to the superior portion of the IVC (~15- pressure while administration. 16cm for Right IJV). Avoid intracardiac advancement and monitor and changes in the II. CENTRAL VENOUS LINE PLACEMENT telemetry monitoring. Indications: 9. Remove the introducer needle while still holding the o Emergency venous access (especially for difficult guidewire in place peripheral IV access) o Confirm placement using sterile bedside o Hemodynamic monitoring of critically ill patients ultrasound if possible o Hemodialysis- and plasmapharesis-requiring patients 10. Make an incision around the guidewire enough to o Long term access for parenteral nutrition insert the dilator over the guidewire Contraindications: 11. Advance the dilator up to ~3-4cm (for Right IJV) o No absolute contraindications while still securing the position of the guidewire o Relative contraindications: 12. Withdraw the dilator while maintaining guidewire § Distorted local anatomy position then apply immediate pressure onto the exit § Local infection on intended site site. § Severe coagulopathy and bleeding disorders 13. Advance the central venous line catheter over the § Thrombosed veins or proximal vascular injury guidewire until desired length is achieved (~16- Potential sites: 18cm for Right IJV) o Internal jugular vein – Right IJV is often the preferred 14. Carefully remove the guidewire site as it provides a more direct route to the right atrium 15. Flush and aspirate all ports with sterile saline o Subclavian Vein – Right subclavian vein also provides 16. Secure the catheter with suture and sterile dressing a direct route to the right atrium but generally has higher over the site. risk for pneumothorax and bleeding 17. Observe for any untoward reactions, and then o Femoral vein – used for patients who have high risk of confirm placement of catheter tip with chest bleeding, but is usually avoided due to increased risk of radiography catheter-related deep vein thrombosis unless the other sites are unavailable III. ECG INTERPRETATION Steps (Intrajugular) ECG placement 1. Prepare materials (Sterile gloves, drapes, gown, o Limb leads mask, antiseptic solution, sterile saline flush, Local § Standard limb leads: I, II, III FOCUS REVIEW CENTER | Focus Review Center | [email protected] | focusreviewcenter.com 2 CLERK COMPANION HANDOUT | INTERNAL MEDICINE § Augmented limb leads: aVR, aVL, aVF o Chest leads How to read? § V1 – 4th ICS, right parasternal border 1. Heart rate (HR) § V2 – 4th ICS, left parasternal border Normal HR 60-100bpm § V3 – between V3 and V4 Tachycardic >100bpm § V4 – 5th ICS, left midclavicular line Bradycardic 100 bpm § Second degree AV block (Mobitz I) P-wave usually buried in QRS complex Ventricular fibrillation Progressive prolongation of PR interval then sudden beat drop (P- wave not followed by QRS complex) No identifiable P-wave, QRS complex, or T-wave § Second degree AV block (Mobitz II) 3. INTERVALS P-wave 0.5V R/S in V5 or V60.12s 6. ISCEMIA/INFARCTION - Incomplete: QRS