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Images and Instruments MedEd Finals Lecture Series ‘23/24 Dr Catherine Coxeter-Smith (FY1) 24th October 2023Layout of Lecture - Station overview - Images - example X-Rays, CT, MRIs - Instruments - airways - Haven’t included menti, but please write your answers in the chat or feel free to unmute - Going too fast, too slow or can’t see the slides - let me know!Station Overview - One of the 12 PACES stations (10 mins) - Usually divided 50:50 between images and instruments but examiner will guide you - Often forgotten in revision, but an easy station to pick up marks Images: - Will get shown 3 images, increasing in difficulty - 1st image: explain as if you’re explain the findings to a patient - 2nd and 3rd images: as if you’re speaking to a colleague Instruments: - Only from the list on MedLearn - Differs slightly between sites. Either all instruments laid out on the bed or the select instruments - Examiner will pick an instrument, ask you what is is, what it’s used for and any complicationsIMAGES Image 1 1. What does this CXR show? 2. This patient is post stroke. What might have happened?A: Right middle zone consolidation ?aspiration SOME TIPS: 1. When discussing x-rays use “zones” not lobes” e.g. The diagnosis would be right middle lobe consolidation but the X-ray shows right middle zone consolidation 2. Right middle zone vs lower zone: a. Middle zone: if the right heart border is obscured b. Lower zone: if the right hemi-diaphragm is obscured 3. Aspiration pneumonia: more likely in the right as the right brain bronchus is more vertical a. E.g. post stroke, post cardiac arrest, post intubation b. Needs abx that cover gut organisms e.g +metronidazoleImage 2 1. What does this AXR show?A: Small bowel obstruction Small Bowel Obstruction Large Bowel Obstruction Location Central Around perimeter Markings Valvulae conniventes - span the entire width of Haustra - don’t span width of bowl bowel Dilation In small bowel (>3cm) Large bowel (>6cm) +/- small bowel (depends if ileocecal valve is competent)Image 3 1. What type of scan is this? 2. What does it show? 3. Is this a chronic or acute presentation? A: chronic subdural haemorrhage 1. CT scan - remember CTs are made of up lots of x-rays..therefore everything appears the same as it does on x-rays e.g. bone is white 2. Subdural haemorrhage 3. Chronic. Chronic blood: black, grey. Acute blood: white.Types of Haemorrhage Intraparenchymal hemorrhage (i.e. haemorrhagic stroke)Image 4 1. What type of scan is this? 2. Diagnosis? 3. Secondary to?A: MRIB showing multiple cerebral mets - More likely mets vs. primary because: - In adults, brain mets are much more common that primary brain tumours - Multiple present vs single - Cancers most likely to met to brain: lung, breast and melanoma NB: Could also be multiple septic emboli e.g. from endocarditisTips for images - next steps… - Practice with friends! - If you get shown an image on placement and you’re not sure why/can’t see the pathology…. ASK! Other resources: ● Radiology masterclass - test yourself (CXRs, AXRs, CTB): https://www.radiologymasterclass.co.uk/tests/quizzes ● More CXR practice: https://litfl.com/top-100/cxr/INSTRUMENTSInstruments overview - List of instruments on MedLearn: https://medlearn.imperial.ac.uk/clinical-skills/glossary/ OR search “clinical skills” on MedLearn - Very brief descriptions on there - will likely be asked more detail that this. - (*imo) DON’T make your own list of instruments etc. Takes a long time, really good resources out there already. List is unchanged from previous yearsAirways - Know the names of each - When would you use each one? - How to size them? - Advantages vs. disadvantages - Definitive airway?Airway Adjuncts (1): nasopharyngeal When to use? - When oropharyngeal airway isn’t tolerated (i.e. gag reflex still intact) - Or too difficult to open mouth e.g. due to trismus in seizures Sizing “Soft-to-soft” = nose → earlobe How to use Size → lubricate end → insert Notes Avoid in ?base of skull fractureAirway Adjuncts (2): oropharyngeal/Guedel When to use? - Reduced GCS, prevents tongue covering airway Sizing “Hard-to-hard” = teeth → angle of jaw How to use Size → insert upside down → rotate to correct position Notes In children, these are inserted the correct way up May still need to continue maneuvers e.g. jaw thrust Not definitive airwaysSupraglottic airway: Laryngeal mask airway (LMA) and iGels When to use? - Reduced GCS in emergencies e.g. cardiac arrests (less training than ET tube needed to insert) - Short theatre cases with low risk of aspiration Sizing Colours correspond to different sizing (green usually for adults) How to use Open mouth and insert. Attach bag valve mask to end Notes Not definitive airways as sit ABOVE vocal cords LMA vs iGel = LMA has inflatable cuff to hold in place whereas iGel uses thermoplastic → body heat softens iGel and holds in placeDefinitive airway: Endotracheal (ET) tube When to use? - Longer surgical cases or higher risk of aspiration - Ventilation (especially if higher pressures required) Sizing Tubes are different diameters How to use **Usually anaesthetics, ITU** 1. Use laryngoscope to visualise vocal cords 2. Insert ET tube past vocal cords 3. Inflate cuff to hold in place 4. Attach ventilator Notes Definitive airway: cuff holds in place below vocal cords. “Seals off” airway to oesophagus - lower risk of aspiration Require specialist training to be able to insertSurgical airways (1): Tracheostomy When to use? - Long-term ventilation e.g. In ITU, using ET tube for several days → may switch to tracheostomy - Trauma to upper airway therefore ET unsuitable How to use **Usually anaesthetics, ITU** 1. Locate the 2-3rd tracheal rings (use Adam’s Apple as surface landmarks and work downwards) 2. Use scalpel to make incision 3. Insert tracheostomy tube 4. Attach ventilator if required Notes Require specialist training to be able to insert Can be long term airway, patients able to be discharged and can talk with practiceSurgical airways (2): Cricothyroidotomy (i.e. emergency surgical airway) When to use? - Emergency, unable to get airway with ET tube or ventilate - E.g. Facial trauma, Obstruction - Cricothyroidotomy >> Tracheostomy in emergency as cartilage easier to access How to use 1. Locate cricothyroid membrane (use Adam’s Apple as surface landmarks and work downwards) 2. Use scalpel to make incision 3. Insert ETT tube Notes Emergency measure, will usually be followed by ET tube or tracheostomy laterInstruments tips 1. Practice with friends out loud! Little and often 2. Watch videos for instruments like chest drains and line insertions. Less likely to see on placement and gives you a better idea of how they’re usedThanks for listening! Please fill out feedback: catherine.coxeter-smith@nhs.scot