INSTRUMENTS

- Dr. K. Zohara Parveen

Father Muller Medical College
Mangalore
 INSTRUMENTS
1. Lumbar Puncture needle 7. Liver biopsy needle
2. Bone Marrow Aspiration & Biopsy
8. red rubber catheter
needle
9. Ryle’s tube
3. AMBU bag and mask

4. Face Mask 10. Foley’s catheter

5. Laryngoscope
11. MDI with spacer
6. Endotracheal tubes
12. Tuning fork
 DESCRIPTION
1. Identify +/- parts

2. Use / Indication

3. Site / method of use / procedure

4. Contraindications

5. Complications
 1. LUMBAR PUNCTURE
• Sterile spinal needle with stillet, 22 – gauge (black), length according to age (1.5‐3.5inch)
• The line connecting the iliac crests should correspond to approximately the L4
spinous process, one to two interspaces above the optimal space to access the
subarachnoid space.
 L.P INDICATIONS
• DIAGNOSTIC

1. CNS infections like meningitis, encephalitis

2. Subarachnoid hemorrhage, GBS

3. Instillation of intrathecal dye for imaging procedures (eg.:

myelography)

4. Measurement of CSF pressure.

 L.P INDICATIONS CONT’D
THERAPEUTIC:

1. Instillation of intrathecal medication( e.g.: chemo in CNS leukemia, methotrexate,

anaesthesia)

2. Benign Intracranial HTN

3. Spinalanesthesia
 L.P CONTRAINDICATIONS

1. Intra Cranial Space Occupying Lesion / Raised intracranial pressure

2. Thrombocytopenia (Platelet count < 20,000) / coagulopathy

3. Local infection at puncture site

4. Severe resp distress/ shock ( may worsen while in flexed position for LP)
 L.P COMPLICATIONS
1. Postdural puncture headache (relatively common)

2. Local back pain

3. Iatrogenic meningitis

4. Spinal hematoma

5. Cerebral herniation (in sudden drop of elevated intracranial pressure)

 GUARDED L.P NEEDLE
Indications:-
• Benign intracranial hypertension
 2. BM BIOPSY / ASPIRATION NEEDLES

BM biopsy ->
BM Aspiration ->
Jamshidi needle
Salah’s needle
 BM INDICATIONS
1. Diseases like leukemia, to detect marrow infiltration in disorders like

lymphomas and other non hematologic malignancies

2. Staging of Hodgkin’s and Non-Hodgkin’s lymphoma, and small blue

round cell tumours of childhood (neuroblastoma, rhabdomyosarcoma and

Ewing’s sarcoma

3. Aplastic anemia

4. ITP (r/o malignancy before starting steroids)

 BM INDICATIONS

5. Bone marrow culture in enteric fever

6. Inadequate or failed marrow aspiration

7. Suspected bone marrow fibrosis

8. Diagnosis of myelodysplastic syndromes and acute megakaryoblastic leukemia

 BM BIOPSY NEEDLE
JAMSHIDI TREPHINE BIOPSY NEEDLE

SITES OF BIOPSY:
1. POSTERIOR SUPERIOR ILIAC CREST ( most
common - because it contains the most
cellular marrow, no vital organs in close
proximity & it’s a non weight-bearing)
2. ANTERIOR ILIAC CREST (in v. obese)
3. ANTEROMEDIAL ASPECT OF UPPER 1/3 OF
THE TIBIA (preferred in kids <18 months
of age)
 BM ASPIRATION NEEDLE
SALAH’S NEEDLE
• PROCEDURE:
1. Palpate iliac crest, Move posteriorly
2. Identify post sup iliac crest
3. Insert needle with twisting motion
Till firmly attached to bone
4. Remove stylet, attach syringe
5. Pull with strong suction into the syringe
6. Make smears immediately
7. Confirm if marrow particles are present
With a pathologist
Withdraw needle, apply pressure bandag
 BONE MARROW BIOPSY
CONTRAINDICATIONS COMPLICATIONS
1. Trauma to the soft tissue
1. HEMORRHAGING DISORDERS
2. Pain
DIC
3. Infection
Coagulation def disorders
4. Hemorrhage – buttocks, thigh,
2. BONE DISORDERS
retroperitoneum
Ostemyelitis
5. Breakage of BM needle (rare)
Osteogenesis Imperfecta
▪ {{People at risk – with thrombocytopenia,
3. SKIN platelet dysfunction, coagulopathy, von
Infection Willebrand’s disease, renal impairment or
obesity and those receiving acetylsalicylic acid,
Recent Radiation therapy to site of
warfarin or heparin }}
sampling
 CAUSES OF DRY TAP

1. Myelofibrosis

2. Aplastic anemia
3. AMBU - ARTIFICIAL MANUAL
BREATHING UNIT - PARTS
 AMBU – INDICATIONS

1. Failed intubation

2. Resuscitation in apnoeic child

3. Respiratory failure- failed oxygenation or ventilation

4. Elective intubation before procedure or in OT

 AMBU BAG SIZES

• 250 ml

• 500ml

• 750ml

• 1600ml – ADULT
 AMBU INLET

WHAT IS THE FUNCTION OF RESERVOIR BAG?

To increase the FiO2 of oxygen to 100%. In case

reservoir bag is NOT used, patient will receive

Oxygen with FiO2 of 40%

WHEN AMBU BAG IS PRESSED, WHERE DOES THE O2

GO? TO RESERVOIR BAG /PT?

It goes to the pt /outlet, as there s a valve at inlet,

A chamber is seen, through which oxygen flows which prevents O2 from entering reservoir, when
continuously from the o2 inlet to reservoir,
without going thru ambu bag ambu bag is squeezed
 AMBU OUTLET

Fish mouth shaped valve at

oxygen outlet ( as seen
There are many small holes below from above), which allows
the yellow rim of the ambu outlet uni directional flow of
through which the pt’s exhaled oxygen, so So, the exhaled
air goes out. air (CO2) doesn’t go back
inside ambu bag
 AMBU

CONTRAINDICATIONS COMPLICATIONS

1. Diaphragmatic hernia
1. Hypo/Hyperventilation

2. Gastric insufflation
2. Severe facial trauma
3. Barotrauma

3. Complete Upper airway obstruction 4. Volutrauma

4. FACE MASK
FACE MASK – PATIENT POSITIONING
FACE MASK POSITIONING
 5. LARYNGOSCOPE
PARTS :
• Handle

• Detachable blade

• Fibreoptic light guide

• Also point out the junction where

the blade hinges onto the laryngoscope

 LARYNGOSCOPE INDICATION:

1. Intubation (asphyxia, resuscitation, meconium aspiration, RDS, Tra

Oeso Fistula )

2. Surfactant administration in newborn RDS

3. Drugs through ET route

4. To detect and remove foreign body obstructing larynx

5. To pass bronchoscope/oesophagoscope/ throat packing

 LARYNGOSCOPE BLADES
TYPES :-
Straight Miller
1. CURVED (Macintosh) – adults paeds
2. STRAIGHT (Miller) – paediatric

Age Miller Blade size

Very Preterm 00
Preterm 0
Term neonate 1
2-10 yrs 2
> 10 yrs 3

Curved Mackintosh
Adults/ older kids
 LARYNGOSCOPY COMPLICATIONS

1. Injury to local tissues – teeth, tongue, palate

2. Stimulation of post. Pharyngeal wall – vaso vagal syncope- hypoxia,

bradycardia. OR vomiting

* Method of use
 [Link] TUBE
1. Identify
Murphy’s eye prevents complete
2. Mention size (written over the cover)
blockage of ET tube in case distal end
3. Cuffed / uncuffed gets impacted with secretions
 ET TUBE – CUFFED/ UNCUFFED
Uncuffed ET
SIZE :- tube starts with
size 2

1. Uncuffed – age/4 +4

2. Cuffed – age/4 +3

❖Cuffed ET tubes used in kids > 8 yrs of age.

❖Function of cuff in ET tube – When inflated, it keeps tube in place &
prevents aspiration of gastric contents.
Q: Why is uncuffed ET tube used in smaller kids?
A: In smaller kids, the narrow subglottic area itself is enough to hold the
ET tube in place, hence uncuffed tubes are used.
 ET TUBE DEPTH
NTG measured from Nose to Tragus of ear to a point midway
1. ET size x 3 (NICU) between xiphoid & umbilicus

2. weight +6

3. NTG + 1cm

4. Age/2 + 12

**Method of insertion

**How to check position

of ET tube
 LARYNGOSCOPY – ET
Why is miller’s blade used in small kid?

Why is uncuffed ET TUBE used in smaller kid?

Anatomy of throat in child- larynx is

funnel shaped, narrower, more

vertical, ant & cephalad, as compared

to adults. Epiglottis is at C3 in newborn

& C5 in adults…. Narrowest portion is

Below Glottis. In older kids, curved,

stronger blade is required to displace

tongue properly.
7. LIVER BIOPSY NEEDLE- VIM SILVERMANN
 LIVER BIOPSY NEEDLE

3 Types:-

1. Trucut

2. Menghini Needle

3. Vim Silverman – bifid needle

• Vim silvermann needle Indication :- liver & kidney biopsy

 LIVER BIOPSY INDICATIONS

1. Cirrhosis

2. TB

3. Storage disorders – Glycogen storage disorder, Wilson’s

4. Malignancy – leukemia, Lymphoma

 PRE‐ REQUISITES BEFORE DOING
LIVER BIOPSY

•Prothrombin Time

•Blood group & crossmatching

•Vitamin K administration before biopsy

 LIVER BIOPSY‐ PROCEDURE

When using Menghini, after making a track with the track maker, the

needle is fitted with a 2 ml syringe containing normal saline and

introduced. The needle is first flushed and then applying a suction force

it is advanced further and quickly withdrawn. The specimen is then

flushed out of the needle

8. SIMPLE RED RUBBER CATHETER
 RED RUBBER CATHETER
• INDICATION – to drain urine, in case of retention of urine

• Made of Indian rubber

• Sterilized by autoclaving, re – usable, temporary use

• COMPLICATIONS: - Trauma, infection

• * procedure – with aseptic precautions- clean, apply lignocaine jelly,

insert catheter till urine comes

9. RYLE’S TUBE

❖ Also called INFANT FEEDING TUBE

❖ Plastic tube with blunt tip (to prevent
injuries while inserting)
❖ Has a marked line to help with proper
placement
❖ Has radio opaque marker so that it can
be easily seen on x ray
 RYLE’S TUBE INDICATIONS
Diagnostic Therapeutic
❖ Gastric lavage – AFB (TB)
❖ Enteral nutrition: feeds
❖ Poisoning – gastric aspirate can be sent
❖ In poisoning - Gastric lavage
for chemical analysis
❖ Intestinal obstruction or Ileus
❖ Tracheo- Oesophageal fistula
conservative management
❖ Internal bleeding in stomach / upper
❖ Drug administration : Surfactant, ORS,
GIT
etc
❖To administer oral contrast for CT in
❖ Decompression of stomach
neurologically impaired child
 RYLE’S TUBE : INSERTION & SIZES
Sizes 5-10 in infants
Age Tube size

preterm 5 Fr

Newborn 5 - 8 Fr

6 mo 8 Fr

1 year 10 Fr

2 - 3 yrs 10 -12 Fr

4 - 10 yrs 12 -14 Fr

> 11 yrs 14 – 18 Fr
 RYLE’S TUBE

CONTRAINDICATIONS:
1. Severe facial trauma

2. Skull base fracture } Risk of intracranial placement

3. Oesophageal stricture

4. Oesophageal varices
 RYLE’S TUBE INSERTION
• Take consent / assent

• Measure NTG to get approx. length of Ryle’s tube to be inserted.(Measure tubing from tip of nose to
tragus, then to the point halfway between the xiphisternum and the umbilicus

• Under sterile conditions, wear gloves, apply lignocaine jelly

• Insert ryle’ tube into nares with child in sitting position and push it backwards

• Ask child to swallow if possible (older child, can offer water)

• Withdraw immediately if tube coils in mouth or there is respiratory distress

• Advance tube till you reach desired depth

• Confirm tube position (either aspirate and check pH using ph strips or attach syringe and push air
into it, auscultate via stethoscope

• Fix tube in position and document the same.

 RYLE’S TUBE
COMPLICATIONS

GIT:

❖ Misplaced – pharynx / Pyriform sinus

❖ Coiling of tube

❖ Oesophagitis – reflux coz of impaired lower oesophageal sphincter

LUNGS: (due to misplaced tube)

❖ Pneumonia

❖ Lung abscess

❖ Tracheal perforation

NOSE:

❖ Alar ulcer & necrosis – large tube unconscious pt

 10. FOLEY’S CATHETER
Self – retaining catheter , made up of
latex
 FOLEY’S CATHETER INDICATIONS
1. Monitor urine output accurately in shock / renal failure

2. To drain urine before , during or after surgery

3. To obtain sterile urine sample for investigations: analysis & culture

4. To differentiate anuria from retention of urine

5. To relieve retention of urine and incontinence

6. For urinary incontinence ,,procedure,,

FOLEY’S CATHETER SIZES
Age Size

Preterm 6 Fr

Newborn – 10 yrs 8 Fr

11-15 yrs 10 Fr

>16 yrs 12 Fr

The above info as per harriet lane

 FOLEY’S CATHETER COMPLICATIONS
❖ Hematuria

❖ Infection

❖ Urethral stricture

❖ Trauma to Urethra / Bladder

❖ Intravesical knot of catheter ( rare)

❖ Paraphimosis due to failure to return foreskin to normal position

following catheter insertion
MDI : METERED DOSE INHALER
INDICATIONS:

1. Treat acute asthma

2. As maintenance therapy for prevention of recurrent

attacks of asthma

ADVANTAGES : as eff as nebulisation

• Multidosing

• Low cost

• Low risk of bacterial contamination

• Decreases oropharyngeal drug deposition

• Reduces oral and systemic side effects, esp with inhaled

steroids
 MDI USAGE
• Has a metal canister containing medicine with propellant

• Canister is inverted and fixed to inhaler before actuating device

• Metered dose inhaler has to be primed before 1st use- to discharge 1-2 doses of medicine prior

to use

• Pt breathes out, puts mouth piece of inhaler in mouth; presses on top of inverted canister and

takes deep inspiration as soon as puff of aerosolized medicine is generated

• Determining when an MDI is empty : is essential. The MDI’s now have an in built dose counter,

which shows zero in RED colour , when its empty.

 DRUGS GIVEN VIA MDI

1. Inhaled β2 agonists:

a) Short acting: Salbutamol, Terbutaline – to terminate acute attack of asthma

b) Long acting : Salmeterol, Formeterol – maintenance therapy in persistent asthma

2. Inhaled anticholinergics: Ipratropium bromide

3. Inhaled mast cell stabilizer : Cromolyn sodium

4. Inhaled steroids: Fluticasone, Beclomethasone or Budesonide

 MDI SIDE EFFECTS

1. Tremors

2. Tachycardia

3. Palpitations

4. Oral Candidiasis – deposition of steroids in the mouth

Disadvantage: requires coordination between inspiration and activation of device,

impossible in smaller kids
SPACER OF MDI
• Mouth piece at one end

• Other end has opening to attach the MDI

• Once canister s pressed, aerosolized drug

enters the spacer.

• By breathing about 10 times, all medicine in

spacer can be delivered to the liungs

ADVANTAGES:

1. Use of spacer eliminates the need for

coordination of actuation and inhalation

2. Increases efficiency and decreases side

effects of MDI
 SPACER CLEANING INSTRUCTIONS

Clean spacer once a week.

Remove mask and take apart the spacer.

Rinse in warm soapy water.

Rinse with clean water and air dry. Do not put in the dishwasher.

Clean the small hole in the MDI once a week with a wet Q-tip.

Replace the MDI when the counter reaches 000. It may continue to spray but no medicine is coming
out.

d/ adv : plastic spacer has electrostatic charge which attracts aerosol particles during first 10-20
actuations, reducing drug deposition in lungs. Reduced by washing with dilute detergent.
 TUNING FORK
• 3 frequency: 128, 256, 512
• Weber and Rinne ‘s tests
• Test Vibration sense: 128Hz tuning fork
THANK YOU