This is study manual for final year medical students for their viva and practical examinations

1. INSTRUMENTS

2. General principles
 Procedures explained and consent obtained
 Sedatives and analgesics given if indicated
 Site prepared with povidone iodine and 70%
alcohol
 Covered with sterile towel exposing area of
interest
 Local anesthetic may be used
 Wear gloves during the procedure

3. Sedatives and analgesics
 Diazepam 0.1to 0.2 mg/kg/dose PO,IM,IV
 Promethazine 0.5 to 1.0mg/kg/dose IM
 Pentazocine 0.5mg/kg/dose iv up to
1.omg/kg/dose IM

4.  Cloral hydrate/triclofos sodium 50mg/kg/dose
PO
 Local anesthesia - Lignocaine 1% maximum
0.4ml/kg use (without epinephrine)
 Restraint: - the method to immobilize the
patient or the part of the body on which
procedure is carried out

5. Lumbar puncture needle
 Identification
Slender long needle with a stylet
G20 to 22 needle - infants and children 1 to 2
inches (sharp beveled spinal needle with
properly fitting stylet)

6. Indications
In confirming the diagnosis of
 Meningitis
 Encephalitis
 Subarachnoid hemorrhage
In evaluation of
 Demyelinating
 Degenerative
 Slow virus infection
 Collagen vascular diseases
 Presence of tumor cells

7.  In relieving raised ICT
In hydrocephalus, pseudotumor cerebri
Benign intracranial hypertension
 For spinal anaesthesia
 Therapeutic
Intrathecal drugs: - TIG in tetanus,
In leukemia (ALL) : methotrexate, cytosine
arabinoside, and hydrocortisone

8.  For various neuroradiological procedures
 Manometric measurements of CSF to assess
ICT or patency of subarachnoid pathways

9. procedure
 Site between L3 L4, or L4 -L5
 A line connecting the highest point of iliac
crests passes through the L4 spine
 Position: - flexed lateral recumbent position
with their back at the edge and perpendicular
to examination cot
 Lie on the side and the neck and the hip flexed

14. Contraindications
 Raised ICT(ICSOL) presence of papilloedema
 Signifcant bleeding tendency
(Thrombocytopenia)
 Local infection at the site of procedure
 Compromise cardio respiratory status
 Meningomyelocele

15.  Symptoms and signs of pending cerebral
herniation
Decerebrate or decorticate posture
Abnormalities of pupil size and reaction
 Critically ill moribund patient

16. Complications
 Local back pain
 Headache: - to avoid, keep head low position
after LP
 infection
 Brain stem herniation

17. Normal CSF
 Color: - water
 CSF pressure: - 70 to 180 mm of water
 CSF volume: - 60 to 100 ml in children (100 to
160ml in adults)
 CSF protein: -10 to 40mg/dl
New born 40 to 120mg/dl (falls to normal
range by 2 to 3mo of age)
Preterm 40 to 300mg/dl

18.  CSF sugar: -50 to 80mg/dl
(2/3 rd of blood sugar, 60% of blood glucose )
NB 30 to 80mg/dl

19. Cells
 Up to 5L/mm3, in NB up to 15L/mm3
 No RBC or polymorphs
 The presence of RBC indicates a traumatic or
subarachnoid hemorrhage
Blood stained CSF centrifuged
 Supernatant fluid clear in traumatic tap,
xantho chromic in sub aracnoid hemorrhage
 Progressive clearing of CSF in traumatic tap

20. Bone marrow study
identification
• Aspiration: - using Salah needle or Klima
needle
• Biopsy: - trephine biopsy
Jamshidi swain bone marrow trephine biopsy
needle
• BM aspiration needle:- Short stout needle
with obturator(stylet), trocar and a guard
• Size: -G18

23. Indications
• RBC: -Aplastic anemia, undiagnosed and
resistant anemias, Megaloblastic anemia
• WBC: - leukemia, Agranulocytosis
• PL: -ITP to rule out leukemia
• PUO, Myelo proliferative diseases
• Lymphoma

24. • Infections
Enteric fever, Malaria, Miliary tuberculosis,
kala azar
• Histiocytosis
• Lipidoses: Gauchers, Nieman pick
• In malignancy to find out secondaries
(Neuroblastoma)

25. • Therapeutic
Bone marrow transplantation,Intra osseous infusion
Site
• In children below 2yrs
Antero medial surface of the upper third of the tibia
• Anterior superior iliac spine
• Posterior superior iliac spine
• Posterior iliac crest
• Sternum

31.  Contra indications
Hemophilia and Christmas disease
 Complications
 Bleeding
 Osteomyelitis
 Tibial fracture
 Injury to growth plate - limb shortening

32. Liver biopsy
 Trans pleural (intercostal)
 Sub costal
Needles
 Vim Silverman needle
 Menghini needle
 Tru cut needle
 Microinvasive gun
 Vim silverman needle - hollow needle, a solid
stylet, and an inner split needle

37. Prerequisites
 Vitamin K 5 to 10mg for 3 days
 PT, Blood grouping and Rh typing
 BP, pulse , abdominal girth noted
Site: -10th right intercostal space in the mid
axillary line

38. Indications
 Neonatal cholestasis
 Intra hepatic cholestasis
 Congenital hepatic fibrosis
 Cirrhosis
 Ch active hepatitis
 Reye syndrome

39.  Undefined portal hypertension
 For enzyme analysis
 Inborn error of metabolism GSD
 For analysis of stored material
Iron, Copper, or specific metabolites
Wilsons disease, hemochromatosis,
hemosiderosis

40. Contra indications
 Prolonged prothrombin time
 Thrombocytopenia
 Suspicion of a vascular, cystic, or infectious
lesion in the path of the needle

41.  Severe ascites
 Marked anemia
 Bleeding diathesis
 Pleural or parenchymal diseases of right lung

42. Complications
 Hemorrhage
 Hematoma
 Creation of AV fistula
 Pneumo thorax
 Bile peritonitis

43. Thoracocentesis
 For diagnosis of nature of pleural fluid, or
therapeutic drainage in large pleural effusion
 Patient sits and leaning forward on to a pillow
or embracing the back rest of a chair
 7th inter costal space in the back near the
posterior axillary line
 Inferior angle of the scapula corresponds to
7th rib

49. • If the aspirate is large/when it is pus
Intercostal drainage tube is inserted in the 4th
space in the anterior axillary line

51.  A Standard pleural tap needle or G18 to 20
canula
Compications
 Hemorrhage, infection , pneumothorax
 Air embolism
 Injury to lung
 Intercostal vessel bleeding

52. Tension pneumothorax
emergency decompression
• Introduce a wide bore cannula in the second
intercostal space in the mid clavicular line.
• The needle or canula should be connected to
a tube(e.g I v infusion set)which is kept
immersed in a bottle of water.
• Air will be seen bubbling through the water,
this must be followed by insertion of chest
tube.

53. Abdominal para centesis
 Empty bladder first
 One of the iliac fossae or the site between the
umbilicus and the pubic symphysis
 Patient lies supine in a reclining position using a
back rest
 G18 to G20 intravascular cannula used.
 Enter the skin and pull the skin slightly down
before entering the peritoneum this creates a Z-
track and avoids leakage of fluid later.

56. • Nasogastric tube/Orogastric tube

57. Nasogastric tube
Ryle's tube/Infant feeding tube
Tip of the tube is blunt with Side holes

61. Uses
In newborn
 For feeding preterm and LBW newborns
 In exchange blood transfusion
 As a urinary catheter in newborn

62.  To assess the patency of esophagus in
esophageal atresia
 Stomach wash in vomiting newborn
 To keep the stomach empty in a newborn with
diaphragmatic hernia
 To diagnose pyloric stenosis operatively

63. Older children
 Gastric lavage in case of poisoning
 To detect upper GIT hemorrhage
 For stomach aspirate (AFB in tuberculosis case )
 For giving medicines and feed in comatose
children
 To give rest to GIT in cases of acute intestinal
obstruction, peritonitis

64. Route
• Orogastric route : -temporary purpose, very
small infants
• Nasogastric route
older children
Uncooperative, unconscious pts when tube is
kept in situ

65. Size of the tube
Size: - no.6 NB,no.8 for esophageal atresia
 Tip of patients little finger serves as a rough
guide to the maximum diameter of the tube
that can pass through the nose

66. Tube length
 For nasogastric intubation: - tube is measured
from xiphisternum to tragus and then to the
bridge of the nose
 For orogastric intubation: - xiphisternum to
nose bridge

67.  Child sits if co operative or lies supine, tube is
lubricated with glycerine (for nasal route).The
tube is pushed down the nose into the
esophagus and down to stomach up to the
marked length keeping the neck flexed.
 Inadvertent passage into the trachea provokes
sudden coughing and choking

68. Tube position is checked
 Auscultation over epigastrium for gurgling on
introduction of air
 Aspiration of acidic stomach contents
 Injection of 1 to 2 ml sterile distilled water
should not provoke coughing and choking
 X -ray shows the exact location of the tip of
tube

69. Feeding
 A 20 to 50 ml syringe containing liquid feed is
attached to the tube and raised above the
head.
 Feed is allowed to flow into the stomach by
the gravity. Plunger is never pushed down.
After the feed, tube is flushed to avoid
clogging and getting plugged.
 After feeding , child lies supine and turn to the
right

70. Lavage
 Small quantities of lavage fluid, generally
saline are introduced and withdrawn
alternatively. child lies on the left and tube
position is varied during the procedure
Tube removal
 Lumen should be closed by pinching and tube
pulled out quickly

71. Tuberculin syringe/Insulin syringe
 In Tuberculin syringe piston is blue in color
and 1ml is divided into 50 or 100 divisions
 In insulin syringe piston is white in color and
1ml is divided into 40 divisions (1 division
 is equal to 1unit of insulin)

77. USES
 To administer PPD for mantoux test
 To administer BCG vaccine
 To administer test dose of drugs(penicillin)
 To test for allergens in bronchial asthma,
atopy
 Insulin injection in diabetes mellites
 Giving small doses of drugs
gentamycin,phenobarbitone,digoxin

78. Tongue depressor
• Metal or wooden tongue depressors
Uses
 To examine gag reflex
 To examine the pharynx,oral cavity & tonsils
 To examine the movements of the palate & the uvula
 Spatula test -to test for the spasm of the masseter
muscles in a suspected tetanus case by trying to insert
the tongue depressor in between the teeth
 To test nasal block

80. Three way canula
• T shaped canula with 2 inlets, 1 outlet, direction
knob
Uses
 To aspirate fluid from empyema, ascites,
pericardial fluid
 Central venous pressure monitoring
 Drugs can be given through one inlet without
removing iv fluid bottle
 For exchange transfusion

81. Transudate
 Liver: - cirrhosis of the liver
 CVS: - CHF, pericardial effusion, constrictive
pericarditis
 Renal: -nephrotic syndrome
 Nutritional: -anemia,hypoprotenemia
 GIT: -protein losing enteropathy
 Dengue hgic fever

82. Exudates
 Peritonitis: - pyogenic, tuberculous,malignant
 Empyema
 Injury to thoracic duct
 Pancreatic ascitis
 Lymphoma,leukemia
 Buudchiari syndrome

83. Transudate/Exudate
• Color:- turbid/straw(TB)
• Protein >3gm/dl
• Ph: - <7.2
• Glucose <50mg/dl
• Pleural fluid protein to serum protein ratio
>0.5
• Pleural fluid LDH to serum LDH ratio >0.6
• Microscopy : -polymorphs, lymphocytes(TB)

84. Scalp vein set
 Needle
 plastic wings
 plastic tube
 adaptor
 Polythene tube
 2 polythene flaps for fixation
 Fine needle to be put inside the vein

87.  Wider end with cap where nozzle of syringe or
IV set is fitted
 Advantage
When caliber of vein is small, in infants and
children it can be easily used
Used over skull scalp veins as they are fixed and
chances of coming out are less.

88. • Inhalation therapy for Bronchial asthma

89. All Asthma Drugs Should Ideally Be
Taken Through The Inhaled Route.

90. Why inhalation therapy?
Oral
Slow onset of action
Large dosage used
Greater side effects
Not useful in acute
symptoms
Inhaled route
Targetdelivery,Quicker
action
Smaller dose, safer
Better tolerated
Treatment of choice
in acute symptoms

91. Aerosol delivery systems currently available
 Metered dose inhalers
 Dry powder inhalers (Rotahaler)
 Spacers / Holding chambers

92. Spacer
Dry Powder
Inhaler
Metered Dose inhaler
Inhalation devices you can use

98. Advantages of Spacer
• No co-ordination of inhalation and actuation
while using an MDI required
• No cold - freon effect
• Reduced oropharyngeal deposition
• Increased drug deposition in the lungs

99. The Zerostat advantage
• Non - static spacer made up
of polyamide material
• Increased respirable fraction  Increased
deposition of drug in the airways
• Increased aerosol half - life  Plenty of time for
the patient to inhale after actuation of the drug
• No valve  No dead space  Less wastage of
the drug
• Small, portable, easy to carry  Child friendly

100. Rotahaler - The dry powder advantage
• Overcomes hand-lung
coordination problems that
are encountered with MDIs.
• Can be easily used by children, elderly and
arthritic patients.
• Can take multiple inhalations if the entire drug
has not been inhaled in one inhalation.

101. Age-wise selection of inhaler devices
• < 3 years – MDI + Spacer + Mask or nebulisers
• 3 – 5 years – MDI + Spacer + Mask or Rotahaler
• 5 – 8 years – Rotahaler or MDI + Spacer
• > 8 years – Rotahaler or MDI + Spacer

102. Patient Education in the Clinic
• Explain nature of the disease (i.e. inflammation)
• Explain action of prescribed drugs
• Stress need for regular, long-term therapy
• Allay fears and concerns
• Peak flow reading
• Treatment diary / booklet

103. Key Messages
• Asthma is a common disorder
• It can happen to anybody
• It is not caused by supernatural forces
• Asthma is not contagious
• It produces recurrent attacks of cough with
or without wheeze
• Between attacks people with asthma lead
normal lives as anyone else
• In most cases there is some history of
allergy in the family.