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Dr Isobel Elliott (F1) Isobel.elliottlucassen@liverpoolft.nhs.uk MENTI CODE IMAGES & INSTRUMENTS A MedED LECTURESESSION STRUCTURE 1. OVERVIEW OF PACES STATION 2. IMAGES • CXR • AXR • Msk XR • CT head 3. INSTRUMENTS • Airways • Some random other instruments 4.MORE IMAGES PRACTICE IF WE HAVE TIME STATION OVERVIEW • 50/50 images & instruments • Images part • 3 different images increasing in difficulty • 1st describe to pt • 2ndand 3 describe to a colleague • Instruments • Lots of different instruments on a table • The examiner will pick a few up and ask you about them • What it is • What its used for • How is it used • Complications IMAGES • DON’T FORGETTHE SIMPLE • NAME, DOB • Date image taken • Would like to compare with a previous image IMAGES- CXR Rotation - Are the clavicles equal distance from the sternum Inspiration - Are there >5 anterior ribs visible Penetration - Can you see the spinous process behind the heart - Is there any part of the body cut off in this image? Exposure IMAGES- CXR Airway - Position of the trachea Breathing - lung markings, opacification, Cardiac - heart size, heart borders Diaphragm - costophrenic angle External/everything else - PPM, NG, sternotomy clips, fracturesIMAGES A- Trachea central, carina and bronchi visualized edge, area of opacification in the Ruppere zone C- heart not enlarged and defined borders no blunting of costophrenic anglehragm, E- nil Impression: R upper zone consolidationIMAGES A- trachea deviated to R B- Complete white out of R lung , L lung markings normal C- mediastinumdeviated to the R, can see the L heart border D- unable to visualize the R hemidiaphragm E- cardiac monitor wires Imp: complete lobar collapse (atelectasis) ?bronchi obstructionIMAGES A- trachea deviated to the R B- loss of lung markings on the L , R side normal C- normal cardiac borders and size D- normal diaphragm E- 2 rib fracture \ Imp: tension pneumothorax likely cause traumatic IMAGES- AXR Bowels – size, walls, contents Other organs – liver, kidneys, bladder Bone – vertebral fractures, boney mets Calcification – eg. aorta, calculi Artefact – catheters, nephrostomyIMAGES – AXR B- dilated loops of small bowel (valvulae conneventae seen) O- liver not enlarged B- no fractures C- no calcification A- no artefact IMAGES – small vs large bowel obstruction SMALL BOWEL LARGE BOWEL LOCATION Central Around parameter MARKINGS Valvulae conniventes (continuous) Haustra (half) SIZE >3cm >6cm CAUSES IMAGES- MSK • MSK XR 1. What is the X ray of and what is the view (AP/ lateral) 2. Alignment – fracture/ dislocation/ subluxation 3. Bone texture 4. Soft tissue IMAGES FRACTURE 1. Fracture of which bone 2. Type of fracture 3. Open or closed 4. Is there displacement? – of the distal bone • Anterior/ posterior • Angulation- varus/ vagus, IMAGES Types offractures Types offracturesIMAGES AP radiograph of L shoulder Transverse fracture of the neck of the humerus Medial displacement of the distal component Closed fractureIMAGES AP radiograph of both hands Erosive subluxation most marked of the MCP joints with ulnar deviation. Prominent degenerative change isalso seen at the ulnar-carpal articulation. Some osteopaenia particularly of the MCP regions. Some soft tissue swelling Advanced features of rheumatoid arthritis IMAGES – CT Air Water White Grey Blood Bone CSF matter matter Oedema (fatty) (cellular) Ischaemia Black = HYPOdense White = HYPERdenseIMAGES – CT brain IMAGES – CT A convex hyperdense area can be seen in keepingwith an extradural haematoma X Dura attaches at suture lines of skull Therefore, bleed doesn’t extend further than suture lines and bulges in LEMON SHAPED XINSTRUMENTSINSTRUMENTS WHAT IS IT/WHAT IS IT USED FOR? • Oropharangeal airway/ guedel • Airway adjunct in obstruction • Stops tongue from occluding epiglottis HOWIS IT USED • Size- teeth to angle of mandible • Insert upside down and rotate in mouth COMPLICATIONS • Laryngospasm if wrong sized used • Damage to soft palate • Not toleratedINSTRUMENTS WHAT IS IT/WHAT IS IT USED FOR? • Igel/ Laryngeal mask • Supraglottic airway • Can be used in emergency settings securing the airway or in short term anaesthesia • Risk of aspiration HOWIS IT USED • Insert correct way round • Inflate cuff (LMA) or igel just moulds to the heat of body • Connect to ventilator/bagvalve mask COMPLICATIONS • Laryngospasm if wrong sized used • Damage to soft palateINSTRUMENTS WHAT IS IT • Endotracheal tube WHAT IS IT USED FOR? • Establishing a definitive airway for mechanical ventilation • Lower risk of aspiration HOWIS IT USED • Laryngoscope to visualize vocal cords • Place ET into the trachea until balloon cuff below vocal cords and inflate balloon • Remove laryngoscope and connect ET to ventilator • Look for chest wall rising and raising end tidalCO2 COMPLICATIONS • Infection - esp pseudomonas • Damage to the surrounding structures • e.g. perforation of the oropharynx, hoarseness ofvoice denoting vocal cord injury, damage to teeth/lips • Incorrect placementINSTRUMENTS WHAT IS IT • Tracheostomy tube WHAT IS IT USED FOR? • Surgical airway • Longterm ventilation • Pt able to tolerate when conscious HOWIS IT USED Locate the 2-3rd tracheal rings (use Adam’s Apple as surface landmarks and work downwards) • Make incision • Insert tracheostomy tube • Attach COMPLICATIONS • Obstruction – haematoma/ mucus • Infection • Fistula formation INSTRUMENTS ADJUNCT NON DIFINITIVE AIRWAY DIFINITIVE AIRWAY • Assists with airway • Mechanical ventilation • Mechanical ventilation obstruction • Connected to oxygen • Connected to oxygen • Not directly connected • Above the vocal cords • Below the vocal cords with oxygen • No cuff inflated • Cuff inflated to prevent it from pulling out • Lessrisk ofaspirationINSTRUMENTS WHAT IS IT • Non rebreather mask WHAT IS IT USED FOR? • Deliver high flow, high percentage oxygen • Emergency situations HOWIS IT USED • attach to oxygen in wall • Inflate reservoirbagby placing finger over valve • Put mask over pt mouth and nose • Can deliver up to 15L 100% oxygen (in reality 85- 90%) COMPLICATIONS • Dry face and mouth • Oxygen toxicity and CO2 retentionINSTRUMENTS WHAT IS IT • ABG needle WHAT IS IT USED FOR? • Arterial blood sample • Useful POC test in emergency settings • pO2 pCO2 pH lactate glucose electrolytes HOWIS IT USED • Feel for strongest part of radial pulse • Insert needle at 45 degree angle • Blood will fill the syringe on its own if in artery • Take to gas machine straight away and keep it rotating to reduce risk of coagulating COMPLICATIONS • Haematoma • pain TIPS! • Look at the packaging- it will usually tell you what it is • If you cant remember the name describe what it does and where you’ve seen it used before on placement and talk your thinking out loud • INFECTION, DAMAGE TO SURROUNDING STRUCTURES • The examiner will usually try to help you – it’s a good stationMORE PRACTICE IMAGES SIGMOID VOLVULUS CAECAL VOLVULUS LOCATION LLQ>RUQ RLQ>LUQ/epigastrum SIGN COFFEE BEAN SIGN FETUS SIGNIMAGES A- Trachea central B- lung markings extend all the way to the edge C- heart not enlarged and defined borders D- air under the diaphragm E- nil Imp: pneumoperitoneumIMAGES – CT A concave area of hyperdensity can be seen in keeping with a subdural haematoma There is also some hypodensity seen which could be in keeping with hyperacute bleed (not had time to coagulate yet) Midline shift to the rightIMAGESIMAGES – CT brain folds, in keeping with SAH, followingthe shape of theIMAGES – CT Hyperdense area on the left and midline shift to the right raised ICP caused by intracerebral haemorrhageIMAGES A- central B- Wide spread fluffy opacification, C- cardiomegaly D- mild costophrenic angle blunting E- In keeping with congestive cardiac failureIMAGESIMAGES – CT Area ofhypodensity on right side in keeping with ischaemic stroke Calcification in the 4 ventricle Hypodense as ischaemic cells are broken down into a watery substance Ischaemic strokes usually don’t show in the initial CTIMAGES Toxic megacolon Lead pipe colon UCWHAT IS IT? • Laproscopic port WHAT IS IT USED FOR? • Minimally invasive laproscopic surgery HOWIS IT USED • one-way allowing a laparoscope and instruments to pass into the abdomen. • 1-1.5 cm incision made in skin then pushed in • C02 passed into abdomen to inflate • Laparoscope inserted through port and then other ports are inserted into abdomen COMPLICATIONS? • damage to internal organs • Bowel perforation • Herniation of bowel through port siteINSTRUMENTS WHAT IS IT? • Chest drain bottle WHAT IS IT USED FOR? • Collects fluid fromchest drain • Can be fluid from pleural space or pericardium • Eg after open heart surgery HOWIS IT USED • Attached to chest drain catheter • Measure volume output • Changed very 48/72hrs COMPLICATIONS? • Infection • Tubing can leak air if not sealed properly INSTRUMENTS WHAT IS IT? • Capillary blood glucose monitor WHAT IS IT USED FOR? • POC detection of blood glucose levels • Important part of A-E workup HOWIS IT USED • Insert test strip and calibrate • Prick side of finger with needle • Touch and hold the edge of the test strip to the drop of blood. • COMPLICATIONS? • Pain • Sclerosis with repeated use NB: capilairy ketone and INR monitors also look similarINSTRUMENTS WHAT IS IT? • Peripherally inserted central catheter WHAT IS IT USED FOR? • Longterm IV access • Administration of TPN, fluids, medication • Can also take bloods fromone HOWIS IT USED • Insert through the skin, into a vein in the arm and normally ended at the lower 1/3rd of the superior vena cava • Can stay in for up to 6 weeks COMPLICATIONS? • Infection • Thrombosis • PhlebitisTHANK YOU &GOODLUCK! PLEASE FILL IN THE FEEDBACK FORM! F eel fr ee to emai l me wit h an y q u esti o n s: I so be l. el l i ot tl uc asse n@ l iv er po o l ft. n hs .u k