InternalMedicin ne:PracticalSkills

1) RYLESTUBEE
Atubewithano openingaton neend&multiplelateralopeningtheotherend.
1stm
marking:esophagealcard diojunction
2ndm
marking:pylorus
3rdm
marking:tipofduodenum m

Indiccations:
1) Diagnosttic
AspirationofbloodupperG GITbleeding,,toconfirm,monitor,acccess
Duod denalaspirattioneg.G.lammblia
Aspirationoftoxxicsubstancesfortoxicolo ogy
Dxtrracheaesoph hagealfistulaa,atresia&d diaphragmatichernia
Gasttrintestfollo owingvagoto omy

22) Therapeutic
Forffeeding
Deco ompressiono ofthechannel
Toreestbowel
Poiso oningcases,todetoxified d
Toreestthestomach,takeouttgastricsecrretion

Conttraindicationn:
Multtiplefacialfractureespcrribriformplate
Esop phagealstrictture
Com matosepatien ntgagreflex,,riskofaspirration
Skulllfracture
Seveeresinusitis

Techhnique:
Non needsedationorspecialp preparation
Posittion:flexheaadwhendiffiiculttoinsert
Main nresistanceisattheupperendoftheeesophagus
Toco onfirmitisin
nthestomacch:1)litmuspaperturnb bluetored,2)nobubblingg,3)pumpairusingsyrin
nge&
ausccultateforbo orborygmi

Commplication:
Perfo oration
Goessintotrachea,thus,aspirrationpneum monia
Trau umaticnasalccavity,thuseepitaxis
Goessupintothebrainincrib biformplateffracture
Disco omfort
Trau umaticinsertiongastritis

2) URINARYCA ATHETER
Typee:
aa) Nondweellingcatheteeratubew withoneopen ningatoneeendandanottheropeninggattheotherrend,for
temporaaryuse
b) Foleysccatheterattubewith4o openings:2aattheend&2smalllateralopeningatttheothereend,alsohasa
balloonaatoneend,h hasvarioussizes,forperm manentuse((longerperiood)


Indiccations:
aa) Nondweellingcatheteer
Temporaryrelieffofcauseuriinaryretentio on
Exclu udeabdomin nalmass
Dxoofhematuria
Dxoofretrogradecystogram

b) Foleysccatheter
Conttinuousbladd derdrainagee(CBD)
Meaasureurineoutput
Insh hockpatient,duringop
ColleecturineforUFEME/C& &S
Canbeusedtoreemoveforeiggnbodyinessophagealinchildren

Conttraindicationn:
Ruptturedurethraa
Infecctionofureth hra
Uretthrastricturee

hnique:
Tech
Asep ptictechniquue
Explaaintopatien nt
Cleanthegenitalliawithcatavvlonanddropthearea
Choo oseasuitableesizeofcath
heter
Appllylignocainejellyatthettipofcatheteer
Hold dcatheterwithforcep
Hold dpenisupwards
Push hcatheterasfaraspossibble
Seeifurinecomeeout
Inflateballoonw withwater
Pullcathetertillffeelresistancce
Conn necttheurinnebag
Strap pcatheterto
otightwithouutanyresistaance

Commplication:
Urettheralrupturre
Pressurenarcosis
Urettheralstricture
Ruptturemembraanousurethrrawhilepullingouttheneckoftheurrogenitaldiap
phragm
Retaainedcatheteertip

3) REDIVACDR RAIN
Suctiondrainorclosesystem mdrainage
Indiccations:
Prop phylacticdraiintopreventthematomaandfluidcolllection
Inheead&necko op
Breaastop
Orth hopedicopegg.Pelvicop

4) LARYNGOSC COPE

Indiccations:

Forintubation
Tovisualizeuppeerrespiratoryytractcautio
onwithfractureof
cervicalspine

5) TTTUBE
Conssists2limbs:oneshort& &onelongwh hichattach
perppendicularto oeachother
Hollo owtubeofvarioussize
Mad deoflatexrubber,whichcaninduceffibrosis,creatteatractand dpreventbileleakage,assaresultredduce
risko
ofbiliaryperritonitis

Indiccations:
InserrtoperativelyduringCBD Dexpioration ndrainage1)TTubeCholangiogram,2)removalo ofresidualstoones,
3)pootencyofbiliiarytract,4)biledrainagee
WheentoremoveeTTube1)daytodaywh henbileoutp putisdecreassing,2)clampptubeby10postopday,,no
pain,3)ttubechholangiogram mshowsbiliaarytractispaatent&thereeisnostoneseen
(N.B.:dailybileo outputis500 01000ml)

Commplications:
Biliaryperitonitiss
Stricctureofcomm monbileducctiflefttoolo
ong
Fistu ulaformation n
Infecctionofwound
Mayyrupturethecommonbilleductduringremoval

6) C CHESTTUBE/INTERCOSSTALDRAINA AGE
Conssistsofmetaltraceandp plasticcannulla
Thecannulahasmultiplelateeralhole&openingattheeotherend& &linedupraadiopaquemmaterial,itstipalso
radioopaque
Markingatthecaannula

Indiccations:
Therrapeutic:todrainair,fluid,blood&p pus
Diaggnostic:typeeoffluiddrainedsentforcytology,C& &S,AFB,FEMME
Forp pleurodesis

hnique:
Tech
Posittion:sittingorsupine
Asep ptictechniqu ue
Clean/drapgivveLA
Inserrtabovetheribs
Toucchtheribs&slitupwardss
Inserrt1cm
Pulltthetrocaoutbytwitchin ngthetroca&&atthesametimepushcannulatill8 8cm
Clam mpthecannu ula&removeethetroca
Conn nectthecann nulatoundeerwatersealeedsystem
Stickkthecannulaa
ChecckwithCXR
Siteofinsertion:air(2ndICSMCL),blood d/fluid(5thICSSMCL)

Commplications:
Dam magetotheneurovascularbundle

Goessintothelunng
Puncctureintomeediastinum
Puncctureintogreeatvessel/peericardium,intrathoracicvessel
hemmorrhage
Infecction(pleurissy,empyemaa,pyothorax))
Slipiin/out
Bronnchopulmonaaryfistula
Subccutaneousem mphysemaairintheskiin
Fractturetotherib

7) SSIGMOIDOSC COPE
Conssistsofmetalobturatorw withmetalcaannula,withmarkingutto30cm,eyepieceandligghtsource

Indiccations:
Diaggnostic:anyp patientswithhlowerGITsyymptomseg.Chronicdiarrhea,PRbleeeding,biopssyofmasses
Therrapeutics:excisionofpolyyps,untwitch hvolvolus

Conttraindication ns:
Analstenosis
Toxiccmegacolon n
Hirch hpurgds
Chro onsds

hnique:
Tech
Nosspecialsedatiion
Don notnecessaryybowelprep parationunleesselectivecases
Posittion:supine,leftlateralp
positionorkkneechest
1stcm mtowardsumbilicus,after4cmreleaaseobturatorr&connecteeyepiece,pu ushthescopeeunderdirecct
visio
on
Atth hesametimee,pumptheairtoinflatethebowelo ortopushblo
ood/fecesaw way
Afterpassingpub borectalismuusclepushdownsacrum
Recttalvalvemayybeseen,pushawayslow wlywithoutfforce
Afterreach1520 0cm(rectosigmoidjuncttion)withdrawslowly&ccountercheckfindings,biiopsyanylession

Commplications:
Perfo oration
Massivebleedingg
Preccipitate

8) SSEBGSTAKEN NBLAKEMOR RE?MINNESSOTATUBE

4lum mens:1)gasstricballoon,2)esophageealballoon,33)gastricasp
piration,4)essophagealaspiration

Indiccations:
Bleedingesophagealvaricesw whichunrespondtovaso opressin

Conttraindication ns:
Unco ooperative,ccomatose

hnique:
Tech
Explaaintopatiennt
Leftlateralpositiion
Sedaation:valiumm/pethidinee

Inserrtthrunose(standingtecchnique)
InserrtlikeRylestube
Aspirate(makessurethetubeeinstomach h)
Inflatecardiacbaalloonwithnnormalsalinee100200ml
Pullttubeout,strrongtractiontothestomach
Inflateesophageealballoon,m maintain30440mmHgpreessure&
mp.Useairbeecauseairiscompressiblee&preventpressure
clam
necrrosis
Checckpressureh hourly,mostimportantisscardiacballo
oonshouldd
deflateafter24hours

Commplication:
Pressurenecrosis
Aspirationpneum monia
Asph hyxia
Ruptture

9) PROCTOSCO OPE
Conssistsofmetalobturatorw withmetalcaannula

Indiccations:
Diaggnostics:hem morrhoid,PR Rbleeding,reectalmasses
Therrapeutics:ru ubberbandin ngforpiles

Conttraindication ns:
Analfissure
3rdd degreepile
Massivebleedingg
Stran ngulated

hnique:
Tech
Posittion:leftlateeral,supine,kneechestp position
Explaaintopt
Inspeectanalmarrginforanyaanalfissure
DoP PRexam
Askp pttotakedeeepbreath,toouchproctosscopetotheanus&inserrtslowly&deeplyintoan
nalcanal
Direcctiontoward dsumbilicus
Then nwithdrawo obturator&wwhileinspecttionslowlydrawoutcannnula

10) ENDOTRACH HEALTUBE

Hasaballoonatoneendand danotheropeeningattheotherend

Indiccation:
Emergency:URTTI,respiratoryyfailure
Electtive

hnique:
Tech
Posittion:supinewithneckexxtended
Rem movealldentu ure
Laryngoscopeho oldonlefthand,insertthroughtrightsideofmoutth&pushto
onguetotheleft,pushin&lift
up

Conttraindication ns:

umaofvocalcord
Trau
Aspirationpneum
monia

11) CCENTRALVEENOUSCANN NULASET

Conssistsofbranu ula&catheteer

Indiccations:
MeaasureCVP
Hypeerlimitation
Med dicationhyp perosmolarssolution
Blooodtransfusion
Collaapsedperiph heralvein
Burn npt
Obessept
Card diaccathetheerization
Temporarytranssvenouscardiacpacemakker
Inserrtionofgasccatheter
Pulmmonaryangio ography

Conttraindicatonss:
Skininfectionatthesiteofinnjury
Seveerkyphoscoliosis
Anydistortionoffanatomy
Childdren<2y/o
Veryythin&oldp pt,becauseppuncturingth
helung
Ptisbleedingdiaathesisorananticoagulan nttherapy
Unco ooperativep pt

hnique:
Tech
Nosspecialsedatiion
Posittion:neckhyyperextended d
Legeend:bedupbecauseofeengorgethevvein&preventairembolism
Apprroach:Rtinteernaljugularrvein,Rtsub
bclavianvein,,Rtbrachioceephalicvein
Asep ptictechniqu ue
LA
Site:mildpartbeetweenstern nanotch&accromionproccess
Makkeasmallnicckwithblade
Usebranulaprovvidedconnecctedto10/20 0mlsaline
Direcctbranulato owardssternanotch
Hitthetipofclavvicle&slided
downintoth
hevein
Asyo ouhit,suckddarkvenousblood
Push hplasticcann nula&withdrawneedle
Conn necttoCVcaatheter

Commplications:
Pneu umothorax
Aireembolism
Infecctions
Hemmatoma
Atriaalfibrillation
Injurrytolung,traacheaesophagus,vesselss&nerves


12) SSTOMA
Openingofintestineorurinarytractonth heabdominaalwalleg.
Coloostomy,ileosttomy,gastro ostomy,vesiccostomy,ureeterstomy

Indiccations:
Asan nalternativeeroutefordischargeofexxcretiondueeto1)
distaalobstructionneg.Congen nitalmalformmation,tumor2)distal leak,
fistulation,injuryy3)postexciisioneg.APrresection,tottal
cysteectomy
Feed dinginproxim malobstruction,anastom mosiseg:Caeesophagus

Typees:
Byanatomiclocaation
Byfu unction,eg.DDiverting,deecompressingg
Bytime,eg.Tem mporary,perm manent
Byco onstruction,eg.Loop,en nd,Mickuliez,,continentp pouch

Setting:
Coun nseling,stom
manurse
Instandingandssittingpositio on
Avoidskincreaseeandfolds,w wound,scarss,bonyprom minence
Thro oughrectusaabdominismuscle
Caree:
Protectskin,eg.Water&bagg
Food d
Irritaation
Supp portgroup,eeg.Stomasocciety

Commplications:
Earlyy:bleeding,ischemia
Late:1)skin(exccoriation,inffection,fistullationChroonsds,variceesportalhyypertension)),2)mechaniical
(prolapsed,strictture,retractiion,paracoloostomyhernia),3)metabolic(fluid&eelectrolytes,nutrition,egg.Fat,
Ca2+,VitaminB12
, 2),4)psycho
ological(depression,sexu ualdysfunctioon,socialdysfunction,alteredbodyimage,
odou ur)

Commponentsofccolostomyap ppliance:

1) Faceplattestomaadhesivewateer+/plasticcring
2
2) Bag/pouchstickon(singleusee)ordetachable,drainableornondraainable
3
3) Othersstomaadheesivepaste& &powder,Karayagum

ILEOSSTOMY COLOSSTOMY
POSITION RIFpoosition Anywh hereespeciallyLIF
CONNTENT Fluid&digestedffood Soft/hardstool
COLO OUR Yellowwish Brown nish/darker
ODOOUR Negative Positivve
SURFACEOPENIN NG Protrusion,irritation Flatoppening

13) TTHROUGHCUTNEEDLE
Conssistsofmetalcannula&m metaltroca

Indiccation:

psyofliver
Biop
Biop
psyofbreast

mplications:
Com
Hem morrhage
Pneu umothorax
Injurrytodiapragm