Venepuncture ~ Basics and Troubleshooting, Vacutainer Colour codes in Blood sampling and tube types used
Venepuncture is the puncture of a vein as part of a medical procedure, typically to withdraw a blood sample or for an intravenous injection.
Veins to be used are:
• METACARPAL VEINS
• CEPHALIC VEIN
• BASILIC VEIN
• MEDIAN CUBITAL VEIN
Attributes of an ideal vein are:
Veins to be avoided:
Methods for improving venous access:
• Apply a tourniquet
• Lower the level of the arm below the heart
• Ask the patient to open and close their fist
• Light tapping / rubbing of the veins
• Relax the patient / consider the environment
• Warm up the patient’s hands
• DO NOT re-touch or palpate the vein once cleaned!!!
• The needle should form a 15 to 30 degree angle with the surface of the arm.
3. PROBLEMS OTHER THAN AN INCOMPLETE COLLECTION:
Haematoma/Bruising can be caused by:
• Tourniquet too tight / left on too long or use of RUBBER GLOVE!
• Arterial puncture
• Repeated insertion sites
If you stick yourself with a contaminated needle:
• Remove your gloves and dispose of them properly.
• Squeeze puncture site to promote bleeding.
• Wash the area well with soap and water.
• Record the patient's name and ID number.
• Follow your hospital protocol regarding treatment and follow-up.
Order Of Draw:
NOTE: NEVER FORCEFULLY EJECT THE COLLECTED BLOOD FROM THE SYRINGE INTO THE VACUUM TUBE.
Causes Of Hemolysis:
Vacutainer Colour codes in Blood sampling:
ACC/AHA Stages Of Heart Failure:
Stage A identifies the patient who is at high risk for developing HF but has no structural disorder of the heart.
Stage B refers to a patient with a structural disorder of the heart but who has never developed symptoms of HF.
Stage C denotes the patient with past or current symptoms of HF associated with underlying structural heart disease.
Stage D designates the patient with end-stage disease who requires specialized treatment strategies such as mechanical circulatory support, continuous inotropic infusions, cardiac transplantation, or hospice care.
This classification system is intended to complement but not to replace the New York Heart Association (NYHA) functional classification, which primarily gauges the severity of symptoms in patients who are in stage C or D. It has been recognized for many years, however, that the NYHA functional classification reflects a subjective assessment by a physician and changes frequently over short periods of time and that the treatments used do not differ significantly across the classes. Therefore, the committee believed that a staging system was needed that would reliably and objectively identify patients in the course of their disease and would be linked to treatments that were uniquely appropriate at each stage of their illness. According to this new approach, patients would be expected to advance from one stage to the next unless progression of the disease was slowed or stopped by treatment. This new classification scheme adds a useful dimension to our thinking about HF similar to that achieved by staging systems for other disorders (e.g., those used in the classification of cancer).
Amiodarone shows considerable interindividual variation in response. Thus, although a starting dose adequate to suppress life-threatening arrhythmias is needed, close monitoring with adjustment of dose as needed is essential. The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the regimen given in above table.
After the first 24 hours, the maintenance infusion rate of 0.5 mg/min (720 mg/24 hours) should be continued utilizing a concentration of 1 to 6 mg/mL (Cordarone I.V. concentrations greater than 2 mg/mL should be administered via a central venous catheter). In the event of breakthrough episodes of VF or hemodynamically unstable VT, 150-mg supplemental infusions of Cordarone I.V. mixed in 100 mL of D5W may be administered. Such infusions should be administered over 10 minutes to minimize the potential for hypotension. The rate of the maintenance infusion may be increased to achieve effectivearrhythmia suppression.
The first 24-hour dose may be individualized for each patient; however, in controlled clinical trials, mean daily doses above 2100 mg were associated with an increased risk of hypotension. The initial infusion rate should not exceed 30 mg/min.
Based on the experience from clinical studies of Cordarone I.V., a maintenance infusion of up to 0.5 mg/min can be cautiously continued for 2 to 3 weeks regardless of the patients age, renal function, or left ventricularfunction. There has been limited experience in patients receiving Cordarone I.V. for longer than 3 weeks.
The abdomen is an anatomical area that is bounded by the lower margin of the ribs and diaphragm above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (such as the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity. Algorithms given below can be used as a quick reference and adjunct to the reader's clinical knowledge and impression.
During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation. It is important to keep in mind that a good estimate of VT versus SVT can be made based on the clinical vignette:
Morphological criteria (if the above criteria are inconclusive)
Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusion: SVT with RBBB
Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT
HAPPY Learning :-)
GOOD LUCK !!!
Thromboelastography (TEG) is a method of testing the efficiency of blood coagulation. It measures the dynamics of clot development, stabilization/strength, and dissolution. Assuming the body’s ability to achieve hemostasis is a function of these clot properties, TEG provides specific, real-time indicators of a patient’s in vitro hemostatic state. This is in contrast to routine screening coagulation tests such as aPTT and PT/INR which are run with blood plasma alone and therefore do not take into account the cellular components of clotting.
TEG creates a graphical representation of the movement of a small pin suspended in a cup of whole blood as hemostatsis occurs. As the blood begins to clot and adhere to the pin, the movement of the pin increases. This increasing movement is interpreted by the computer as increasing amplitude on the TEG graph.
A small sample of blood is taken from the selected person and rotated gently through 4º 45', six times a minute, to imitate sluggish venous flow and activate coagulation. A thin wire probe is used to measure, which the clot forms around. The speed and strength of clot formation is measured in various ways, typically by computer. The speed at which the sample coagulates depends on the activity of the plasma coagulation system, platelet function, fibrinolysis and other factors which can be affected by genetics, illness, environment and medications. The patterns of changes in strength and elasticity in the clot provide information about how well the blood can perform hemostasis, and how well or poorly different factors are contributing to clot formation.
Four values that represent clot formation are determined by this test: the reaction time (R value), the K value, the angle and the maximum amplitude (MA). The R value represents the time until the first evidence of a clot is detected. The K value is the time from the end of R until the clot reaches 20mm and this represents the speed of clot formation. The angle is the tangent of the curve made as the K is reached and offers similar information to K. The MA is a reflection of clot strength. A mathematical formula determined by the manufacturer can be used to determine a Coagulation Index (CI) (or overall assessment of coagulability) which takes into account the relative contribution of each of these 4 values into 1 equation.The G-value a is log-derivation of the MA and is meant to also represent the clot strength using dynes/sec as its units. There are some studies which suggest that an elevated G-value is associated with a hypercoagulable state and therefore increases the risk for venous thromboembolic disease. However, there are no studies dosing of prophylactic heparin products based on the G-value. TEG also measures clot lysis which is reported as both the estimated percent lysis (EPL) and the percentage of clot which has actually lysed after 30 minutes (LY 30,%). Although a normal EPL can be as high as 15% and a normal LY 30 can be has high as 8%, some studies in the trauma population suggest that a LY30 greater than 3% is associated with risk of hemorrhage.
Thromboelastometry (TEM), previously named rotational thromboelastography (ROTEG) or rotational thromboelastometry (ROTEM), is another version of TEG in which it is the sensor shaft, rather than the cup, that rotates. Blood (300 µl, anticoagulated with citrate) is placed into the disposable cuvette using an electronic pipette. A disposable pin is attached to a shaft which is connected with a thin spring (the equivalent to Hartert’s torsion wire in thrombelastography) and slowly oscillates back and forth. The signal of the pin suspended in the blood sample is transmitted via an optical detector system. The test is started by adding appropriate reagents. The instrument measures and graphically displays the changes in elasticity at all stages of the developing and resolving clot. The typical test temperature is 37°C, but different temperatures can be selected, e.g. for patients with hypothermia.
Sonoclot is the latest version of Thromboelastography which takes into account the initial viscosity changes (which typically happens before Fibrin polymerization) and later the elastic changes of the developed clot.
Case 1: 14 year-old male who presents with a chief complaint of rash. He states the rash came on over the past week and he also has noticed spots of blood when he blows his nose. He does not take any medications or supplements. On physical exam you note flat, red, non-blanching lesions on his bilateral lower legs. As you begin to examine his nose he starts to exsanguinate from the nares.
Case 2: 26 year-old male arrives in the ER 30 minutes after sustaining 2 Gunshot wounds to the chest. Vitals: BP 60/40 HR 115 O2Sat 88% on nonrebreather. Resuscitation is started and you send off a TEG.
Case 3: 42 year-old female arrives in the ER 40 minutes after an Motor Vehicle Collision in which she was ejected from the car. Emergency services reports they found her significantly obtunded with a large contusion on her forehead and obvious bilateral femur deformity. Vitals: BP 110/60 HR 107 O2Sat 93% on room air. As the R3 prepares for intubation you notice that she has significant bleeding around the site of her IV. You send off a TEG.
Which TEG parameters are abnormal?
HAPPY LEARNING :-)
Let us know about your experiences with this investigation in the comments section below.
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Mnemonic for the side effects of Phenytoin
P: Pheripheral Neuropathy, P-450 interactions
E: Enlarged gums
Y: Yellow-browning of skin
O: Osteomalacia (due to enhanced vitamin D metabolism)
I: Interference with folic acid absorption (hence megaloblastic anemia)
N: Neuropathies: vertigo, ataxia, headache
1. The first step in screening for acute intermittent porphyria is to order a
A. blood protoporphyrin assay
B. genetic screen
C. urine porphobilinogen (*)
D. urine uroporphyrin
E. therapeutic trial of phenobarbital
Abdominal swellings may be divided into generalised and localised
swellings. Abdominal swellings are a common surgical problem.
They are also frequently the subject of examination questions!
Generalised swellings are classically described as the ‘five Fs’, namely
fat, faeces, flatus, fluid or fetus. For the purpose of description
of localised swellings, the abdomen has been divided into seven
areas, i.e. right upper quadrant, left upper quadrant, epigastrium,
umbilical, right lower abdomen, left lower abdomen and suprapubic
hepatomegaly (See Differential of hepatomegaly)
Secondary to carcinoma of the head of the pancreas
Wilms’ tumour (nephroblastoma)
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