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Foot Drop

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FOOT DROP: WHAT TO DO IN THE ED? • First, establish course of disease, is it chronic or acute? • Chronic (~90% of cases): • Bilateral more common than Unilateral • Most likely doesn’t need an extensive work-up while in ED • Important for neurology follow-up for • Acute (~10% of cases): • Unilateral more […]

Low Risk Chest Pain

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The Shownotes on Low Risk Chest Pain The management of low risk chest pain in the US is founded on a number of tenets: If low risk chest pain patients are sent home and they have unstable angina, they will do worse than if we admitted them Provocative testing will identify patients who are safe […]

Lumbar Puncture (LP)

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Foam Needs Soap Summary Traumatic tap 1 WBC:750 RBC (Roberts and Hedges)   Tests to order: Cell Count Chemistries (Glucose, Protein) Culture/Gram Stain Latex Agglutination (If gram stain negative with suspicion) Cytology-if suspicion of tumor Fungal/AFB/Crypto/VDRL if immunocompromised If you suspect crypto, get opening pressures and closing pressures   A measurement of opening pressure should […]

Thoracentesis

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To find the level, use UTS or put stethoscope on the back and tap the sternum with your fingers…   What to Send Red tube (LDH, protein, glucose, amylase, triglycerides, and perhaps albumin) Lavender (cell count) ABG syringe for pH CX bottles Two extra tubes Extra red to hold Bag for cytology (or green top) […]

Pulmonary Artery Catheters (PAC) / Swans

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Pulmonary Artery Catheters ” a fool with a tool is still a fool.” Primer on PAC pressure interpretations: http://intensiveblog.com/puzzling-pac-pressures/ The reference range for PA pressure values is: RAP = 0-6 mmHg RV = 25/0 mmHg PAP = 15-30/5-15 mmHg PAOP = 2-10 mmHg Pulmonary Artery Catheter Insertion Is the PAC reallyyyy dead?? put hand on […]

Cervical Injection for Headache

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http://journals.lww.com/em-news/Pages/videogallery.aspx?videoId=4&autoPlay=true http://journals.lww.com/em-news/blog/M2E/pages/post.aspx?PostID=5 http://journals.lww.com/em-news/Fulltext/2014/11000/Emergentology__A_Needle_in_the_Neck.4.aspx

Burr Holes and Skull Trephination

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UC Davis Cheat Sheet Acad Emerg Med 2011;18:78   Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. (J Emerg Med. 2010 Sep;39(3):377-83.) Authors Smith SW, et al. Show all Journal   doi: 10.1016/j.jemermed.2009.04.062. Epub 2009 Jun 17. Affiliation Comment in      J Emerg Med. 2012 Dec;43(6):e489-90.  Abstract  BACKGROUND: Blunt head […]

Atrial Fibrillation and Atrial Flutter

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  Chemical Cardioversion Ibutilide 1 mg over 10 minutes Avoid if EF<20% or QTc>480 must observe for 4 hours to make sure no QT prolongation augments electrical cardioversion (NEJM 1999;340(24):1849     ashman beats from variable repolarization of the bundles Holiday heart=etoh generated a-fib, can also be from withdrawal. Usually spontaneously resolves.   P-ulmonary Embolism […]

Alternative Anticoagulants

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Obstetric Critical Care Management

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Review Article (J Intensive Care Med. 2006 Sep-Oct;21(5):278-86) Vent Stuff ↑ alveolar ventilation (20-40%), ↑ TV, ↑ RR Compensated hypocarbia (Normal 25-32 and normal bicarb 18-21) Mechanical ventilation- need to adjust for PaCO2 30-32 (compensated hypercarbia); no studies show harm with permissive hypercarbia Faster desaturation: ↑ O2 consumption + ↓ function residual capacity + ↑ […]

Podiatry

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Athlete’s Foot prescribe products containing terbinafine such as lamisail AT Toenail Fungal Infections What’s the best treatment for toenail fungus? There’s no magic bullet. Lamisil (terbinafine) taken daily for 12 weeks works best. But, long-term success hovers only around 50%. It can cost upwards of $240 per month. It costs less if given in pulse […]

Hemophilia and von Willebrand’s Disease

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Hemophilia A x linked recessive causing defective VIII:c, Abnormal ptt. Replace c cryoprecipitate of factor VIII 1 unit=100 units VIII 1 cc of FFP=1 unit VIII and less of IX dDAVP raises factor VIII by causing release from endothelial cells, It has ADH-like effects.  Dose:  0.3 mcg/kg. Number of units=0.5 x (Desired Factor Level) x […]

Morel-Lavallee Lesions

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From the Trauma Professional Blog Their experience led them to develop the following practice guideline: Bottom line: The Morel-Lavallee lesion can be challenging to treat. Although this study has limited numbers, it provides enough guidance to suggest a consistent way of managing it. I recommend adopting this algorithm to provide a standard pathway for dealing […]

Old TOC

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Resuscitation and General Principles Management Airway Management A New Airway Curriculum Physiology of Preoxygenation Ventilatory Management ? Basic Vent Stuff Waveforms Pulmonary Toilet and Medications Non-Invasive Ventilation Airway Pressure Release Ventilation (APRV) High Frequency Ventilation Independent Lung Ventilation Recruitment Maneuvers Oxylator Nitric Oxide Weaning/Liberation and Extubation Lab Interpretation and ABGs Oxygen Transport & Physiology of […]

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Cardiothoracic Surgical Intensive Care

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best book: Manual of Perioperative Medicine by Bojar Post-CABG what was bypassed? discrete lesion vs. diffuse disease what was the graft material? art vs. vein, pedicle vs. free Looking for MAP 70-80 and DBP>50 First 6 hours, need CI>2.0 Hb 8.0 Fix acidosis CVP is actually a good monitor of RV failure Consider SWAN if […]

Bed Bugs

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Oliguria and Urinary Electrolytes

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Post from Nickson on Life in the Fast Lane USES Oliguria UNa+ low (<10mmol/L) – extravascular volume depletion UNa+ high (>20) – tubular damage Hyponatraemia UNa+ low (<10) – extra-renal losses UNa+ high (>20) – renal salt losing states, SIADH, diuretic therapy Fractional excretion of Na+ = 100 x UNa+ x PCr / PNa+ x […]

Blakemore Placement

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Blakemore Tube My BP manometer with the adapter from the salem sump test for leaks evacuate air and put in plugs HOB 45 pass it to at least 50 cm numbers on tube should face the right lateral portion of the esophagus on the Bard tube get xray 250-300 cc air in the gastric balloon […]

Lipid Rescue

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Caution with interpreting laboratory results after lipid rescue therapy. Punja M et al. Am J Emerg Med 2013 Aug 8 [From the Excellent Poison Review] No abstract available This short case report from Emory University and the Georgia Poison Center makes the point that administering lipid rescue therapy (LRT) may affect laboratory results in ways that […]

Pulmonary Artery Catheter (PAC, Swan)

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  RudolfI am fan of using of PACs long time ago. I am just try to utilize the cardiac cycle to move it. It looks like a boat floating through the heart. First; i have to think if i really need it and it will affect the patient’s outcome? Are there any alternatives? Second; I […]

Tracheostomy and Trach Emergencies

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Head-of-Bed Signs and UK Trach Safety Project http://tracheostomy.org.uk//Templates/Algorithms.html When to Trach Consider when > than 14 days of intubation are planned. Risks include: Tracheoinnominate Artery Fistula (TIA)-causes severe airway bleeding which can be fatal.  Consider hyperinflating the cuff to tamponade bleeding as temporizing measure.  In differential of any bleeding >48 hours after placement. Tracheoesophageal Fistula […]

Airway Carts

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Airway Carts Open endotracheal tubes may be safely left on an ED airway cart for 48 hours. (Am J Emerg Med. 2005 Jul;23(4):548-51.) CONCLUSION: It appears that opening, preparing, and storing ETTs in an ED airway cart for up to 48 hours does not increase the risk of bacterial contamination of the ETTs. Sterility of […]

Pericardiocentesis

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Pericardiocentesis 16-18G sheath for initial entry inject agitated saline to confirm 5-7 fr introducer or pigtail J Cardiovasc Ultrasound 1988;7:193 for description of procedure   From Bret Nelson: In this study, a para-apical approach was deteremined to be the optimal site for paracentesis in 2/3 cases: Tsang TS, et al.: Consecutive 1127 therapeutic echocardiographically guided […]

Video Laryngoscopy

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Markdown Syntax from John Gruber’s Site

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Markdown Syntax from Daring Fireball: Markdown Syntax Documentation Inline HTML For any markup that is not covered by Markdown’s syntax, you simply use HTML itself. There’s no need to preface it or delimit it to indicate that you’re switching from Markdown to HTML; you just use the tags. The only restrictions are that block-level HTML […]

Extracorporeal Removal Techniques in Toxicology

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From (J Intensive Care Med 2012;25(3):139) Characteristics of Xenobiotics That Are Cleared by ECR For all 3 techniques Low volume of distribution (Vd; <1 L/kg), that is, not in tissue Single-compartment kinetics Low endogenous clearance (<4 mL/min per kilogram) For hemodialysis MW <500 Da (little data on high-flux membranes) Water soluble No plasma protein binding […]

Supraglottic and Extraglottic Airways (SGAs and EGAs)

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LMAs CLINICAL SKILLS FOR THE PREHOSPITAL USE OF THE LMA Similar to the first laryngoscopy,41 the first LMA insertion attempt should be optimized. Is the Correct LMA Size Selected? The LMA Classic is available in six sizes. The manufacturer recommends two size selection criteria: weight based (for adults patients: size 3, 30 to 50 kg, […]

Blind Nasotracheal Intubation

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Consider awake BNTI in a predicted difficult airway   start with 32 french trumpet anesthetize through it to get post pharynx   Use the left nostril or if using the right turn tube 180°   Facilitated by neutral head position and ET tube cuff inflation to 15cc.   depth is 26-28 cm at nares   […]

Central Line Placement

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Central Venous Catheters and Central Venous Access Central Lines IJ Lines Go straight through medial portion of lateral head of SCM muscle.  (J. Cardio Vasc Anes 8:6) Femorals Higher Infection Rate, Higher Thrombosis Rate than subclavian (French, Prospective Trial JAMA 286:6, 2001 JB   ) Study of cath related infection shows Subclav<IJ<Femoral (Intensive Care Medicine Volume […]

Cricothyrotomy

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Heard’s CICO algorithm (Anaesthesia 2009;64:601) Cricothyrotomy (Surgical) Stand at pt’s right (if you are right hand dominant, otherwise reverse all sides) Left hand holds thyroid cartilage with index finger touching membrane. Make a vertical incision from thyroid cartilage to above jugular notch. Make horizontal stab incision through cricothyroid membrane Drop trach hook into incision with […]

ICU Management of Brain Tumor

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acutely bring NA up to 150 until post-op with 3% infusion and 23.4% boluses. After op, continue 3% or 2% to maintain sodium within 10 of plateau, keep weaning slowly over 48 hrs post-op at which point can transition to NS   Steroids Decadron 10 mg continue 8-32 mg/day posterior fossa will need slow wean […]

Bronchoscopy

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Bronchoscopy simulator online http://www.bronchoscopy.org/ for training and maybe even better http://www.thoracic-anesthesia.com/?page_id=2&langswitch_lang=en   need 2mm larger ET tube than diameter of scope, so 8mm tube to use adult size bronchoscope Anaesthesia 2012, 67, 1042–1056   Procedure from Practical Bronchoscopy Some bronchoscopists prefer to face the sitting or lying patient whilst others stand behind the head of […]

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Bath Salts

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This class of drugs are chemically altered hallucinogenic stimulants. Depending on which chemical is used in the salts, the patient can look like they took meth or ecstasy. They will present with a sympathomimetic toxidrome including hyperadrenergic vitals and profound hyperthermia. Here is a link to Leon’s Gussow’s bath salt article in EM News. Scott […]

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Toxic Shock Syndrome

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Toxic Shock Syndrome (TSS) Toxic shock syndrome presents with high fever, rash and hypotension.  Prodrome of malaise, low grade fever, myalgias and vomiting.  Sx may occur 2-3 days after tampon use, soft tissue infection, or within a week of other inciting factors. Rash is a diffuse, non-pruritic, blanching, macular erythroderma leading to desquamation. Clinical Criteria […]

Le Roux’s Review of Transfusions for SAH

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From (Neurocritical Care 2012;16:343) The Risks of Blood Transfusion in Patients with Subarachnoid Hemorrhage: Response to Dr. Paul E. Marik Peter Le Roux and Michael Diringer To the Editor, We read Dr. Marik’s letter with interest. He makes some valuable comments and is correct when he states: more research is needed. We respectfully disagree, however, […]

Aortic Operative Stuff

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Posted by: “Dr.Mohamed El Tahan” on Anesthideas   However, did your surgeon prepare the bypass machine with extra reservoir !. In reality, as your description this is ATA III post traumatic aortic dissection and massive bleeding is normal. First, i would to clarify this missed point which raised by Dr. Bilal and you, this may […]

Patient Satisfaction

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Alkalemia – Metabolic and Respiratory Alkalosis

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Alkalemia hypokalemia (and sensitization to dig related arrhythmias) reduction of ionized calcium leading to neurologic symptoms Stimulates anaerobic metabolism Metabolic Alkalosis Plasma bicarb>45 seek to lower it to Nasogastric Suction/Vomiting Diuretics-from increased loss of urinary electrolytes and water. Cl loss balanced by reabsorbtion of bicarb, H+ moves into cells to allow eflux of K. Mg […]

Malpractice

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On Average, Physicians Spend Nearly 11 Percent Of Their 40-Year Careers With An Open, Unresolved Malpractice Claim Health Aff January 2013 32:1111-119; New York State Medical malpractice actions must be filed within thirty months of the date of the act or omission that gave rise to the injury occurred. For malpractice actions based upon the […]

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Medication Reconciliation

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“Screening reconciliation” for all ED patients should include routinely obtaining from each patient at each ED visit a list of the patient’s current medications (usually done by the triage nurse). “Focused reconciliation,” as directed by the emergency physician, based on medical relevance, should include seeking additional information about the patient’s medications (exact drug list, dosage/route, […]

Trauma Teams

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Severe Traumatic Brain Injury

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Neglected phases of TBI-apneic and catecholamine surge Severe injury=GCS<8 Suspect elevated ICP if: GCS<8 or GCS ≤ 10 and: Hematoma volume > 30 ml (A,B,C,/2) Midline Shift > 1 cm Pineal shift > 5 mm Compression of the Lateral Ventricles CT Interpretation New BTF Recs B. Level II Blood pressure should be monitored and hypotension […]