Echocardiography, CSF study, IV and IM injections

1. Pediatric
Echocardiography
By:Zaid Rasheed

2. What is echocardiography ?
•It is a noninvasive, portable, and efficacious
sonographic imaging study that helps in
1) providing detailed anatomic structure of
heart
2)hemodynamic, and physiologic information
about the pediatric heart

3. Indication
•1- Congenital Heart Disease
•2-Acquired Heart Disease
•3-Arrhythmia

4. Congenital heart diseases
• It should be suspected in the presence of
• Cyanosis
• Failure to thrive
• Exercise-induced chest pain or syncope
• Respiratory distress
• Murmurs
• Congestive heart failure
• Abnormal arterial pulses
• or Cardiomegaly
• Certain syndromes, family history, and extracardiac abnormalities
that are known to be associated with congenital heart disease

5. Acquired Heart Disease
• 1- Kawasaki disease
• 2-infective endocarditis
• 3-cardiomyopathies
• 4-rheumatic fever
• 5-SLE (lead to myocarditis)
• 6-pericarditis
• 7-HIV infection
• 8- Exposure to cardiotoxic drugs

6. Arrhythmias
• > Children with arrhythmias may have underlying structural cardiac
disease such as
1) congenitally corrected transposition
2) Ebstein's anomaly :tricuspid valve of the
heart does not form correctly and is
lower into the right ventricle than normal.

7. Types of Echocardiograph
1) Transthoracic Echocardiograph
2) Trans esophageal Echocardiograph

8. Transthoracic Echocardiograph
1)Most common type
2)Painless
2)Non invasive

9. Trans esophageal Echocardiograph
• . A specialized probe is passed into the patient's esophagus. This
allows image and Doppler evaluation which can be recorded.
Indicated
1)Inadequate transthoracic quality image
2)cardiac source of embolism,
3)endocarditis,
4)prosthetic heart valve dysfunction,
5)native valvular disease,
6)and aortic dissection or aneurysm

11. By:
Media Ahmed

12. • Origin of CSF: Most CSF is formed in the ventricular
system. Possible sites of origin include the choroid
plexus (~ 80%), the parenchyma (~20%)
• Formation rate: Clinical studies have indicated the
formation rate of CSF to be about 20 ml/hour or 500
ml/day in adults and children. The total CSF volume is
age-dependent but reaches the adult volume of 150
ml by age 5 years
• Component : water 99% , glucose , lactose, Na+, Mg+
,Cl- , Ca+, K+.
Background

13. Lumber puncture
Cisternal puncture uses a needle placed below the
occipital bone (back of the skull).
Ventricular puncture may be recommended in
people with possible brain herniation. A hole is
drilled in the skull, and a needle is inserted directly
into one of brain's ventricles.
CSF may also be collected from a tube that's
already placed in the fluid, such as a shunt or a
ventricular drain.
CSF aspiration types:

14. Lumber puncture
Indications
I. Suspicion of meningitis or encephalitis.
II. Suspicion of subarachnoid hemorrhage (SAH)
III. Suspicion of central nervous system (CNS) diseases such as Guillain-Barré
syndrome.
Contraindications
I. Absolute
 infected skin over the puncture site
 increased intracranial pressure (ICP) from any space-occupying lesion (mass,
abscess)
II. Relative contraindications
 bleeding diathesis or coagulopathy

15. Equipment
• Sterile dressing
• Sterile gloves
• Sterile drape
• Antiseptic solution with skin swabs
• Lidocaine ## diazepam , Midazolam
• Spinal needles
• Four (three) plastic test tubes (microbiology,
chemistry , hematology and cytology)
• Spinal manometry is not routinely performed in
children during lumbar puncture.

17. Positioning AND procedure
Take consent
Lumbar puncture may be performed with the child
lying on their side or sitting up.
Patient should lie on his side with his knees drawn
as close to his chest as possible and chin toward
his chest or sit ( arms and head resting on a table).
Cleaning the back with an antiseptic sterile cloths
(called drapes) will be placed around the area.
Draw an imaginary line between the top of the iliac
crests. This intersects the spine at approximately
the L3-4 interspace

18. CONT…
Pierce the skin with the needle and pause.
ensure that back is vertical, needle is parallel to the bed
and perpendicular to the back
Advance the needle into the spinous ligament (increased
resistance). Continue to advance the needle within the
ligament until there is a fall in resistance.
Remove the stylet. If CSF is not obtained replace the stylet
and advance the needle slightly then recheck for CSF.
After you collect CSF you should re-insert the stylet and
then remove the needle.
Apply sterile dressing.

19. Patients who are immunocompromised
Patients with known CNS lesions
Patients who have had a seizure within 1 week of
presentation
Patients with an abnormal level of consciousness.
Patients with focal findings on neurologic examination
Patients with papilledema seen on physical examination, with
clinical suspicion of an elevated ICP
Indications for performing brain CT scanning
before lumbar puncture

20. ØHeadache is most common (hours or days).
ØTransient/persistent paresthesiae/numbness
(very uncommon)
ØHerniation is the most serious complication
ØHematoma
ØNeural injury.
ØInfection
complication

21. Normal Leukocytes
0-5/μl
lymphocytes
Glucose
40-80mg/dl
Protein
10-45mg/dl
Crystal
appearance
100-100000
polymorphic
Cloudy or
turbid
10-1000
lymphocyte
normal
50-1000
lymphocyte
Cloudy or
viscus
Bloody
TB

22. Insertion of Iv line and Im
Injections
By: halima muhammad

23. What is Iv line?
Intravenous (IV) cannulation is a technique in which a cannula is placed inside a vein
to provide venous access
Two types :
• peripheral.
• central..

24. Peripheral
• simple
• inexpensive
• used for short term therapy
• has to be replaced every 72 to 96 hours
Central
• Used for long term therapy .
• used when large quantities of
i.v fluids , blood .... are
required.
• harmful medications like
chemotherapy
• poor venous access

26. Indications
• Repeated blood sampling
• IV administration of fluid
• IV administration of medications
• IV administration of chemotherapeutic agents

27. • IV NUTRITIONAL SUPPORT
• IV ADMINISTRATION OF BLOOD OR BLOOD PRODUCTS
• IV ADMINISTRATION OF RADIOLOGIC CONTRAST AGENTS FOR
• COMPUTED TOMOGRAPHY (CT), MAGNETIC RESONANCE IMAGING (MRI), OR NUCLEAR IMAG

28. Contraindications
No absolute contraindications for IV cannulation exist.
Peripheral venous access in an injured, infected, or burned
extremity should be avoided if possible.

29. Technique
Place a venous tourniquet over the patient’s nondominant arm,
and select a site for IV catheter insertion. The veins of choice for
catheterization include the cephalic or basilic veins, followed by the
dorsal hand venous network.
If difficulty is encountered in finding an appropriate vein, one of
the following techniques may be used:
• Inspection of the opposite extremity
• Opening and closing the fist

30. • USING GRAVITY (HOLDING THE ARM DOWN)
• GENTLE TAPPING OR STROKING OF THE SITE
• APPLYING HEAT (WARM TOWEL/PACK) OR A NITROGLYCERIN OINTMENT
 Apply an antiseptic solution (eg,70% alcohol) with
friction for 30-60 seconds , Allow to air-dry for up to 1 minute
to ensure disinfection of the site and to prevent stinging as the needle pierces the skin.
Once the skin is cleaned, do not touch or repalpate it.
 Hold the venous access device in your dominant hand
with the bevel facing upward

31.  The angle of the needle entry into the skin will vary according to the device used
and the depth of the vein. Small superficial veins are best
accessed by using a small catheter (22-24 gauge) placed at a 10-25º angle
.Deeper veins should be accessed with a larger catheter at a 30-45º angle.
 Upon entry into the vein, the practitioner might feel a “giving way” sensation.
Blood should appears in the chamber of the venous access device (ie, flashback).
The angle of the venous access device should be reduced
to prevent puncturing the posterior wall of the vein. It should be advanced gently
and smoothly an additional 2-3 mm into the vein.

32.  If no blood is observed in the flashback chamber, the device should be withdrawn
to just beneath the skin level, and another attempt to recatheterize the vein
should take place. Flashback may stop if the device has punctured the posterior
wall of the vein or if the patient is extremely hypotensive. If swelling develops,
withdraw the device, release the tourniquet, and apply direct pressure for
5 minutes for a hematoma.
 If venous catheterization is unsuccessful, the needle should never be
reintroduced into the catheter. This could result in catheter fragmentation and
embolism.

33.  Release the tourniquet. While applying pressure to the catheter to prevent
blood spillage
 Secure the venous access device to the skin using the transparent dressing
and tape
 Finish securing the tubing to the skin using tape. Place a label indicating
the date, the time, and other facility-specific required information over t
he transparent dressing

35. Complicatios
• Pain
• Failure to access the vein
• Difficulty flushing after the catheter was placed in a vein
• Arterial puncture
• Thrombophlebitis
• Peripheral nerve palsy
• Compartment syndrome
• Skin and soft tissue necrosis

36. Intramuscular injection
• An intramuscular injection is a technique used to deliver a medication deep into the
muscles.

37. Uses
doctor may use an intramuscular shot if:
• they cannot locate an appropriate vein
• the particular drug would irritate the veins
• the digestive system would render pills ineffective

38. Locations
Upper arm
• The deltoid muscle is the most common site for vaccines. This
muscle is in the upper arm near the shoulder.
• It can only receive small volumes of medication, usually 1 milliliter
or less. Therefore, doctors do not use it for drugs that require larger
quantities.

40.  The hip
• Healthcare professionals often give intramuscular injections into the
ventrogluteal muscle of the hip.
• This muscle is a very safe injection site for adults and infants more than
7 months old because it is thick and located away from major nerves and
blood vessel

42.  THE BUTTOCKS :
• In adults and children they tend to avoid using these muscles now because
of the potential risk of injury to the sciatic nerve.

43.  THE THIGH :
 To locate the correct spot, imagine dividing the thigh vertically into three equal
parts.
 Give the injection into the outer top part of the middle section.

45. Technique
Wash the hands
Gather supplies
• an alcohol wipe
• a sterile gauze pad
• a cotton ball
• abandage
• THE medication
• a new needle and syringe

46.  Prepare the injection site
 Prepare the vial and syringe
 Inject the medication
• Insert the needle into the muscle at a 90-degree angle. Use the index finger
and thumb to stabilize the syringe while using the other hand to pull back on
plunger slightly to look for blood.If there is blood, it means the needle is in a
blood vessel and not a muscle. Withdraw and start over with a new needle
, syringe, and injection site.
• If there is no blood, the needle is in the correct position. Press down on the
plunger of the syringe to inject the medication.

47.  Remove the needle
Press on the injection site
Using gauze, apply light pressure to the injection site.
Light bleeding at the
injection site is normal,
but a person can use a bandage if necessary.

49. Complications
• an abscess, or collection of pus
• tissue necrosis, or tissue death
• granuloma,
• muscle fibrosis,
• Tissue hematoma,
• injury to blood vessels and nerves

50. • severe pain at the injection site
• prolonged or excessive bleeding
• tingling or numbness around the muscle
• redness, swelling, or warmth at the injection
site
• drainage at the injection site

51. Contraindications
Generally you should avoid sites of Infections , lesion , lump
presence of nodules or other pathologies .