• Name

• Indication
• contraindication
• How to confirm correct
placement
• complication
 RYLE’S TUBE
• DIAGNOSTIC: UGIB
• THERAPEUTIC: Nutrition/ Aspiration of intestinal obstruction/decompress
stomach

• Technique:
– Needs pt cooperation
– Ask pt to swallow (put lignocaine at the tip)
– Insert according to marker, measure 1st
• Correct placement:
– Ascultate, balloon it
– Aspirate content: litmus paper blue-red
– Xray (Has radio-opaque at the distal end)

• Cpx: aspiration pneumonia, trauma, perforation, esophagitis

• Contraindication: severe facial/ basal skull fracture
 CHEST TUBE INSTRUMENTATION
• Indication: tx-drainage of pneumothorax/hemothorax/pleural effusion
• Dx- drain fluid and send to lab
• Instrument: trochar, cannula, artery forcep, lignocaine, syringe, needle, sea water, povidone, spirit, etc
• Site: safety triangle: A border latissimus dorsi, L border of pect major, 4-5 ICS
• Function: ask pt to cough, see fluctuant, bubbling
• When to remove- when x serve fx anymore: no more fluid, blocked
• Complication
immediate-bleeding, trauma to adj organ : lung, internal mammary gland, injure brachial artery,
long thoracic nerve
– Late: infection, fistula, tube blockage/ dislodge, subcutaneous emphysema

• How to insert:
– Consent
– Position-45 d, supine
– Safety triangle.
– Aseptic-clean and drape
– Give LA
– Open technique- incise 3-4cm
– Use artery forcep to make blunt incision
– Insert finger, feel for pleura
– Insert tube, connect with underwater seal, anchor
• Creates one-way valve that allow air to
escape through the drain but not to re-
enter the thoracic cavity.

• The drainage bottle should always be kept

below the level of the patient, otherwise
its contents will siphon back into the chest
cavity.

• Persistent bubbling of air through the

water indicates an air leak from the lung.

• Chest tubes should NEVER be clamped for

any reason, to avoid tension
pneumothorax.

• The air outlet of the underwater seal may

be connected to moderate suction (-20cm
water) to assist in lung re-expansion. This
is more important in the presence of an
air leak.
 Sangstaken Blackmore tube
• Indication- bleeding esophageal varices
• Esophageal balloon: yellow (pump air 30-40mmHg)
– Decompressed 4 hourly 15-30min
• Gastric balloon: red (pump 200cc water)
• Green-aspirate gastric content
• Cannot use > 24H- use sclerosing therapy
• Cpx
– Pressure necrosis
– Aspiration pneumonia
 OSCE

5. Picture
A. Identify this device.
B. Give 2 indications.
C. Give 2 sites for insertion of this device.
D. How would you confirm its proper placement?
E. Name four complications associated with the use of this
device.
 ANSWER
Identify this device.
Central venous catheter (Length? Lumen?)
Give 2 indications.
Rapid admin IVF / administer inotropic drug / cytotoxic drug/ TPN/ monitor hydration.

CVP- measures pressure RA: 3-10mmHg (5-10 cmH2O), connect to a manometry

Low reading: fluid loss (hypovolemia), excessive diuresis/extravasation
High CVP : hypervolemia, cardiac failure, lumen obstruction, hyperviscosity (after blood tx)

Give 2 sites for insertion of this device.

Short line : Internal Jugular Vein / Subclavian vein
Long line : Brachial vein

How would you confirm its proper placement?

Chest X-Ray

Name four complications associated with the use of this device.

Pneumothorax / bleeding-puncture artery such as carotid, subclavian, basilic / infection / hemothorax..
• Triple lumen foley
catheter
• Continous Bladder
irrigation
– hematuria
 Suprapubic catheter
indicated for acute urinary retention, bladder outlet obstruction (eg BPH,
post-vulvectomy, urethral stricture).

complications include UTI, catheter site bleeding/infection.

advantages: more hygienic coz far from genitalia, patient can change own
catheter, sexual activity less affected.

disadvantages: any tube entering bladder provides route for infection, urine
may still leak via urethra if catheter blocked.
 Solutions
• Differentiate crystalloid & colloid
• Which u prefer for resuscitation? Why
• Content of normal saline, hartmann’s,
gelafundin
• Complication of overhydration
Crystalloid
Volume expander
Has electrolytes: na, k, cl,
lactate
Normal saline, hartman’s,
dextrose
Use in resuscitation, rapid
action
Rapidly excreted by kidney,
virtually unchanged
Preferred for dissolution and
iv drug admin
Colloid
Volume expander
Has starch/protein. Larger
molecule, Stays longer in the
circulation
Increase oncotic pressure. So,
draws fluids back into
circulation.
Gelafundin, haemaccel (hi
gelatin), dextran-high
molecular weight dextrose
Good in maintaning bp
-not in acute: allergy rxn, fluid
overload
• NS- na, cl
• HM- na, k, cl, lactate, ca. Caution in lactate acidosis.
– Prevention- & replenishment of re­duced circulatory blood volume &
interstitial fluid by replenishing water and electrolytes in E.C.F. under the
following types of stress: Before, during and after surgery. Trauma, scalds and
burns etc.,
• Ringer’s solution- na, k, cl, ca
• Gelafundin
– gelatin, nacl, cacl, water
– For acute blood loss, tx & prophylactic hypovolemic shock, burns, frost-bite
 ENTERAL PARENTERAL
Definition Feeding tru the GIT Feeding via blood stream
(bypass GIT)
Ways NG tube (if got swallowing Central-TPN
incoordination) Peripheral-PPN
Gastrostomy (total obs @
esophagus for long term)
Jejunostomy (if
gastrectomy, GERD)
Indications Impaired digestion GI incompetency
Inability to consume Hypermetabolic state with
adequate nutri orally poor enteral tolerance /
Impaired digestion, accessibility
absorption, met
Severe wasting / depressed
growth
advantages Cheaper Provides nutrients when <
Less invasive 2 to 3 feet of small
Less cpx intestine remains
Preserve gut integrity &
immnuno fx Allows nutrition support
Decrease likelihood of bac when GI intolerance
translocation prevents oral or enteral
support
complication N/V/D Catheter – pneumothorax,
Gastric retention air embolus, bleeding
Hyperglycemia Thrombophlebitis
Aspiration Septisaemia
Gasteroenteritis coma Met: hyperosmolar
Tube displacement symptoms, hyponat
Leakage/prolapse
Enteral feeding
parenteral
Radiographs
Pneumothorax with rib # at 7th rib
pneumothorax
Image shows a benign lesion: a
fibroadenoma with well-defined
edges and a halo sign. The Halo
sign in mammography refers to
radiolucent rim (halo) around a
lesion and is generally but not
always indicative of the
benign breast lesion.

Malignant vs Benign
Image shows a malignant-type lesion: an invasive ductal carcinoma. This stellate
(spiculated) lesion has ductal-type microcalcifications.
Benign microcalcifications: cystic hyperplasia.
 Breast Mammography
• Comment on
– Breast symmetry
– Size
– General density
– Glandular distribution
– Masses
– Densities
– Calcifications
– Architectural distortions
• For masses, analyzed
– the shape
– margins
– Density
 Breast ca Malignant Benign
Calcifications Breast Ca
Usu small <0.5mm
Often
Larger.
usually coarser,
pleomorphic/ often round with
heterogeneous smooth margins,
shp/fine granular and more easily
fine linear, or seen
branching (casting)
shape
Density > normal breast Very low density,
tissue. such as that of fat,
is seen in benign
lesions (eg, oil cyst,
lipomas,
galactoceles,
hamartomas
irregular and
spiculated margins

Benign calc-eggshell calcifications in cyst walls, tramlike in arterial walls, popcorn

type in fibroadenomas, large and rodlike with possible branching in ectatic ducts,
and small calcifications with a lucent center in the skin.
Staghorn calculi
Staghorn calculi
Air under diaphragm
Air under diaphgram
Small IO
Small IO
Large IO
Sigmoid volvulus – coffee bean/inverted U
Normal ERCP
Filling defects, irregularity of CBD, dilated CBD
Fluoroscopic image taken during ERCP. Multiple gallstones are present in the
gallbladder and cystic duct. The common bile duct and pancreatic duct appear to be
patent.
 ERCP
• Diagnostic:
– view the biliary tree and
– Find out cause of obstruction
– biopsy
• Therapeutic
– Stone removal
– Sphincterotomy
– Stent/balloon dilatation
• Complication
immediate- perforation, bleeding, infection, cardiopulmonary events
late-infection a/w indwelling stents, pancreatitis, cholangitis, duodenal hge

• Contraindications
– Coagulapathy
– Esophageal obstruction
– Anaphylaxis rxn to dye
Intracranial hemorrhage. CT scan of right frontal intracerebral hemorrhage
complicating thrombolysis of an ischemic stroke.
Intracranial hemorrhage. Fluid-attenuated inversion-recovery, T2-weighted,
and. gradient echo MRI illustration of intracerebral hemorrhage associated
with a right frontal arteriovenous malformation
Intraventricular hrrge
Extradural/epidural hematoma
Subdural hemorrhage
Epidural hemorrhage
Subdural hemorrhage - Axial head CT scan revealing a large bilateral
hemispheric chronic subdural haematoma with mixed high and low density,
which represented new bleeding into an old haematoma
Non-contrast computed
tomogram showing bilateral
subdural haematomas, the
right greater than the left with
midline shift. The right
subdural haematoma is
exerting quite a marked mass
effect with effacement of the
cerebral sulci.
 Intracranial
Hemorrhage

Intraxial/cerebral
Extraaxial
hemorrhage

Intraparenchymal Intraventricular Epidural Subdural Subarachnoid

 4 Questions
• What are the causes?
• What are the clinical signs?
• How do you manage?
• What are the complications?
 Pneumothorax
• Comment on :
– Loss of lung markings / area of reduce opacity /
lung collapse
– Bullae?
– Rib fracture?
– Mediastinal shift?
– Deviation of trachea?
– Chest tube?
– Lung collapse?
 Pleural Effusion / Hemothorax
• Comment on:
• Opacity, meniscus sign/air fluid level
• Pneumothorax?
• Pneumonic changes / area of consilidation (lung cancer)
• Mediastinal shift?
• Massive?
• Chest tube?
 Often missed…
• Subcutaneous emphysema
• Rib fracture
 Intestinal Obstruction
• Comment on:
– Large intestinal : >5cm, haustration, inverted
U/coffee bean
– Small intestinal : valvulae conniventes/stack of
coins
– Pneumoperitoneum – Rigler Sign
 Choledocholithiasis
• Comment on:
• Filling defects due to obstruction/presence of
stones
• Dilatation of common bile duct
 OGDS
• Indications
– Therapeutic
– Diagnostic
• Bowel Prep?
– 4-6 hours fasting
• Complications
– General
– Specific
– Late
 Colonoscopy
• Indications
– Therapeutic
– Diagnostic
• Bowel prep
– 3 days b4
– 1 day b4 – 5+2=7+2=9
• Complications
– General
– Specific
– Late

***If got renal impairment, give fortrans. 12pm-2pm-4pm