Lumbar Puncture Practical Skills Teaching Year 3 Medical Students MB BCh 2012-2013
Contents Introduction to workshop... 3 Overall Session Aim... 4 Intended learning objectives... 4 Workshop Structure Guidance for Tutors... 5 Introduction:... 6 Assessment:... 7 Appendix A Questions and Answers... 8 Appendix B Procedure Checklist... 10 Appendix C - Useful resources:... 11 SW & AM September 2012 Page 2
Introduction to workshop Welcome! Thank you for agreeing to participate in Year 3 Practical Skills Teaching. The workshop outcomes for the students are to learn the skills required to perform a lumbar puncture in the adult patient. We also hope to use the opportunity to ask the students to develop their communication skills as this can be an unsettling procedure for the patient. This procedure is invasive and has potentially serious adverse outcomes. The students must learn to communicate these risks so as to allow for an informed consent. At the end of the workshop we will be asking you to complete evaluation forms. Please give as much information as you can, as we will use this data to develop the workshop for 2013/14. Just as a reminder, more information about this skill is found at the Clinical Skills Resource site for tutors. The link to the module is: http://medic.cardiff.ac.uk/clinicalskills/ Please find the Lumbar Puncture module within the list of e-modules. We are aiming for the students to be: Accurate Efficient Compassionate Thank you again for your participation. The Clinical Skills Team SW & AM September 2012 Page 3
Overall Session Aim For students to provide practical evidence of their competency in performing the clinical procedure of lumbar puncture Intended learning objectives By the end of this workshop the students should be able to: 1. Describe the anatomy of the lumbar spine in relation to the spinal cord and the spinal nerve roots. 2. Describe the major indications, complications and side effects of lumbar puncture, including those required for informed consent. 3. Demonstrate correct aseptic technique for obtaining cerebrospinal fluid (CSF) during lumbar puncture and measuring the opening pressure. 4. Display a professional manner and good communication skills towards the patient (student colleague) if present, and throughout the skills simulation session. 5. Evaluate own learning and recognise how improvements can be made. SW & AM September 2012 Page 4
Workshop Structure Guidance for Tutors Please Note: Students arrive 15 minutes prior to taught session for registration and housekeeping Taught Session Time: 45 minutes Session Progression Additional Resources Lumbar Puncture 9 minutes Introduction Interactive teaching demonstrating the relation of the spinal cord and nerve roots to the vertebral column. Which structures the needle passes through to obtain CSF. What CSF is What CSF can be tested for and which laboratories perform these tests 9 minutes Demonstration Full demonstration of a lumbar puncture by Tutor to include sterilisation, local anaesthetic, needle insertion, pressure measurement and sample collection. 2 minutes Questions and Answers Students given the opportunity to ask any questions that may have arisen during demonstration 20 minutes Practice Students work in pairs and practice performing a lumbar puncture Tutor to support and lend guidance where necessary Tutors to encourage patient / student communication Student pair can act out student-patient relationship Tutor to assess each student s ability to successfully obtain a pressure measurement and a sample of CSF 5 minutes Discussion and Final Question and Answer Recapitulate on the session and address any questions that have arisen Spinal Model Spinal Diagrams Lumbar Puncture and Epidural Simulator Mk2 -- Lumbar Puncture and Epidural Simulator Mk2 -- SW & AM September 2012 Page 5
Introduction: Lumbar puncture is a procedure whereby a needle is passed through the dura at the level of the lumbar spine, in order to either obtain a sample of cerebrospinal fluid (CSF) for diagnostic purposes, to relieve raised pressure within the brain, or to precede injection of drugs. Indications Diagnosis of: meningitis, encephalitis and subarachnoid haemorrhage Administration of anaesthetic drugs Administration of antibiotics and cytotoxic drugs Contra- Indications Evidence of an intracranial spaceoccupying lesion, raised intracranial pressure Evidence of spinal cord compression Prolonged clotting time Risks Infection Epidural Haematoma Neurotoxicity Side Effects Headache Local infection at site of needle insertion Septicaemia SW & AM September 2012 Page 6
Assessment: For the purposes of this workshop, students will be assessed on a formative basis, that is, by observation and feedback on their performance with the aim of encouraging further practice and improvement. Throughout the session it is proposed that a series of questions are posed to the students (see appendix A) encouraging each student within the group to answer at least one of the questions asked. SW & AM September 2012 Page 7
Appendix A Questions and Answers Question Answer 1 For what three reasons would you perform a lumbar puncture? 1. To relieve raised pressure within the brain 2. Obtain a sample of cerebrospinal fluid (CSF) 3. To precede injection of drugs 2 What three things would a lumbar puncture help to diagnose? 1. Meningitis 2. Encephalitis 3. Sub-arachnoid haemorrhage 3 At what level of the spinal cord is a lumbar puncture usually performed? 4 In the midline there are three main ligaments that must be penetrated before the spinal space is reached. Name the three ligaments L3/4 and L4/5 interspaces 1. Tough supraspinous ligament 2. Interspinous ligament 3. Ligamentum Flavum 5 Where is the CSF contained? Within the dural sac (sub-arachnoid space) 6 Complete the following paragraph... Epidural haematoma Nerve root Spinal cord Blood coagulation defects increases the risk of ******** ********* with consequent ***** **** and ****** **** compression that can be devastating The paragraph reads: Blood coagulation defects increases the risk of epidural haematoma with consequent nerve root and spinal cord compression that can be devastating 7 In what five circumstances should a lumbar puncture not be performed? 1. Evidence of an intracranial space-occupying lesion, raised intracranial pressure 2. Evidence of spinal cord compression 3. Prolonged clotting time 4. Local infection at the site of needle insertion 5. Septicaemia SW & AM September 2012 Page 8
8 What is the common side effect of a lumbar puncture? 9 What is the root cause of headache which is induced? 10 How long should a patient be advised to lie flat for post procedure? 11 What helps resolve the post procedure headache? 12 If caffeine and hydration do not resolve the headache what alternative procedure might help? Headache The amount of CSF that is lost, which in turn is related to the size and type of needle used to perform the lumbar puncture At least 30 minutes Good hydration and caffeine Blood patching SW & AM September 2012 Page 9
Appendix B Procedure Checklist Obtain full consent from the patient Collect together the required equipment and enlist the help of an assistant Position the patient so that they are sitting up or on their left side. If they are on their side, use a sandbag or rolled up cloth to ensure that the spine is as straight as possible. Remember, if it is a diagnostic lumbar puncture it needs to be done on the left side position The patient will need to flex the lumbar spine as much as possible, so ensure that the patient is comfortable in a flexed position Mark the midline and posterior superior iliac spine if necessary Do a full surgical scrub, put on a surgical gown and sterile gloves Clean the skin over the anticipated injection point Use a disposable fenestrated drape to cover the surrounding area and maintain a sterile field Infiltrate the skin with local anaesthetic using a small orange needle Wait 3-4 minutes for anaesthetic to work Infiltrate deeper structures with a longer green or blue needle Wait 3-4 minutes for the anaesthetic to work Introduce the spinal needle through the skin at 90 degrees, identifying each ligamentum flavum, epidural space and into the spinal space. Measure the CSF pressure using the supplied manometer Send off three to four samples of CSF for microscopy and culture, protein and glucose, with paired blood samples Fully remove the spinal needle, and press firmly with a sterile swab over the puncture site for at least two minutes Cover the site with an occlusive dressing Instruct the patient to lie supine for at least 30 minutes Dispose of sharps, gloves and drapes appropriately Wash hands Record the procedure in the patient s notes, including the position it was performed in, the intervertebral space you used, the needle type used and the opening pressure measurement. SW & AM September 2012 Page 10
Appendix C - Useful resources: Patel, N. and Knight, D. 2009. Clinical Practical Procedures for Junior Doctors. Churchill Livingstone: Elsevier Dornan, T. and O Neill, P. 2006. Core Clinical Skills for OSCEs in Medicine. Churchill Livingstone: Elsevier Turner, R., Angus, B.J., Handa, A. and Hatton, C. 2009. Clinical Skills and Examination: The Core Curriculum. Wiley-Blackwell Stoneham, M. and Westbrook, J. 2007. Invasive Medical Skills: A Multimedia Approach. Blackwell Publishing Athreya, B.H. 2010 Handbook of Clinical Skills: A Practical Manual. World Scientific Thomas, J. Monaghan, T. 2007. Oxford Handbook of Clinical Examination and Practical Skills. Oxford Medicine Online SW & AM September 2012 Page 11