UMEM Educational Pearls - By Haney Mallemat

Do you like placing ultrasound-guided IV catheters? Check out this trick for covering the probe during the procedure.

http://ultrarounds.com/Ultrarounds/The_Vascular_Probe_Protector.html

or

https://www.youtube.com/watch?v=ZuOq6Ea_FbA&feature=plcp

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Question

33 year-old male found unconscious by EMS and complains of right shoulder pain upon waking up in the ED. Diagnosis? 

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Previous pearls have described the increasing evidence against colloid (e.g., hydroxyethyl starch) use during resuscitation. Now it appears that the crystalloid 0.9% normal saline (NS) may be under fire. 

The use of large volumes of NS has been associated with hyperchloremic metabolic acidosis and harm in animal studies. The risk of harm in humans, however, has been less clear. 

Bellomo et al. conducted a prospective observational study in which patients being resuscitated in the control group received NS at the clinicians' discretion; i.e., chloride-liberal strategy. The use of NS was restricted in the intervention group, where other less chloride containing fluids were used for resuscitation (e.g., Ringer's Lactate); i.e., a chloride-restrictive strategy. 

The authors found that when compared to patients in the chloride-liberal group, the chloride-restrictive group had significantly less rise in baseline creatinine, less overall AKI, and a reduced need for renal replacement therapy.

Bottom line: Although this was only an observational study, the liberal use of normal saline during resuscitation may increase the risk of AKI and renal replacement therapy. 

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Question

11 year-old male is tackled and falls on his outstretched hand while playing football. X-rays are shown below. What's the diagnosis?

 

 

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Question

33 year-old male in respiratory distress. What's the diagnosis?

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Category: Critical Care

Title: Sugar isn't always so sweet

Posted: 10/22/2012 by Haney Mallemat, MD (Emailed: 10/24/2012) (Updated: 10/24/2012)
Click here to contact Haney Mallemat, MD

A study by Perner, et al recently published in NEJM observed that using hydroxyethyl starch (HES) as a resuscitation fluid increased mortality and renal replacement therapy at 90 days as compared to lactated acetate.
 
Another recent trial, called the “Crystalloid versus Hydroxyethyl Starch Trial” (CHEST) was a prospective randomized control trial from Australia comparing the use of 6% HES and 0.9% sodium chloride as a resuscitation fluid in the critically ill. 
 
With 7,000 patients enrolled (3,500 in each group), the CHEST trial is the largest single-trial of HES to date; the primary outcome was 90-day mortality and secondary outcomes were acute kidney injury (AKI) and renal-replacement therapy
 
The study concluded that there was no difference between groups for either morality or renal failure, but significantly more patients in the HES group required renal replacement therapy.
 
Bottom line: There is still no convincing data that patients receiving HES as part of their resuscitation have better outcomes compared to crystalloid (normal saline or lactated ringers) and there is increased harm with their use. Furthermore, the increased cost of HES does not appear to justify their routine use.

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Question

Trauma patient (...yes, that's the only history you're given). Diagnosis?

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Question

35 year-old male unrestrained driver following motor vehicle crash presents with blunt chest injury. There are multiple injuries on CXR (can you find them all?), but what's up with his right lung?

 

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Question

70 year-old male recently treated for community-acquired pneumonia presents with bloody diarrhea, fever, and severe abdominal pain. Abdominal Xray is shown below. Diagnosis?  

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Category: Visual Diagnosis

Title: What's the Diagnosis? Image by Dr. Jason Adler

Posted: 10/7/2012 by Haney Mallemat, MD (Emailed: 10/8/2012) (Updated: 10/8/2012)
Click here to contact Haney Mallemat, MD

Question

26 year-old male from Indonesia presents with severe abdominal pain and weight loss for the past two months. He also states he found this "worm" in the toilet (see below) after a bowel movement. What is the medical treatment for this condition? 

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Category: Visual Diagnosis

Title: A Safer Way to Suture?

Posted: 10/1/2012 by Haney Mallemat, MD (Emailed: 10/2/2012) (Updated: 10/2/2012)
Click here to contact Haney Mallemat, MD

Do you place central-lines?

Do you suture your central-lines into place?

Do you ever get worried that you are going to stick yourself with that needle?

If you answered yes to any of these questions, then maybe this pearl is for you; click here

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Intubated patients may occasionally meet certain criteria for extubation while in the Emergency Department. Extubation is not without its risk, however, as up to 30% of patients have respiratory distress secondary to laryngeal and upper airway edema, with some patients requiring re-intubation.

Prior to extubation, Intensivists use a brief “cuff-leak” test (deflation of the endotracheal balloon to assess the presence or absence of an air-leak around the tube) to indirectly screen for the presence of upper airway edema and ultimately the risk of re-intubation. The cuff-leak test is performed by deflating the endotracheal balloon followed by one or more of the following maneuvers:

  • Using the ventilator to measure the difference between inspired and expired tidal volumes; if there is a difference in the measured volumes, then air is “leaking” around the endotracheal tube, implying minimal airway edema.
  • Auscultation for an air “leak” around the tube during mechanical ventilation; auscultation of a leak implies that air is passing around the tube and minimal airway edema is present.
  • Disconnecting the patient from the ventilator and occluding the endotracheal tube during spontaneous breathing; auscultation of a leak implies that there is air passing around the tube and minimal airway edema is present.

Ochoa et al. performed a systematic review to determine the accuracy of the “cuff-leak” test to predict upper airway edema prior to extubation. The authors concluded that a positive cuff-leak test (i.e., absence of an air-leak) indicates an elevated risk of upper airway obstruction and re-intubation. A negative cuff-leak test (i.e., presence of an air-leak), however, does not reliably exclude the presence of upper airway edema or the need for subsequent re-intubation.

Bottom line: No test prior to extubation reliably predicts the absence of upper airway edema. Patients extubated in the Emergency Department require close observation with airway equipment located nearby.

 

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Guide-wires can be challenging to dispose of after central-line insertion because they are difficult to keep on the field, hard to place in the sharps box, and can splash nearby observers.

Click here for this little guide-wire disposal trick.

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Question

27 year-old woman with AIDS presents complaining of a painful, puritic, and papular rash. What's the diagnosis?

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Question

40 year-old male with severe uncontrolled hypertension presents with altered mental status (head CT below). The CXR is from the same patient. What's the connection?

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Question

40 year-old male with severe uncontrolled hypertension presents with altered mental status. Head CT is shown here. Name three common anatomic locations generally seen for non-traumatic intracerebral hemorrhage. 

 

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Question

32 year-old female presents with 5 days of fever, chills, and flank pain. She is hypotensive on presentation and urinalysis shows pyuria. Click here for the non-contrast CT scan. What's the diagnosis and what type of antibiotics should be started empirically?

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A Cochrane review of 37 studies concluded that Succinylcholine (SUC) is superior to Rocuronium (ROC) during rapid sequence intubation.

The authors claim that compared to ROC, SUC has a faster onset of action (45 vs. 60 seconds) and overall a shorter duration of action (10 vs. 60 minutes).

Dr. Reuben Strayer wrote a letter to the journal editors and stated that these findings should be interpreted carefully; he highlighted that most of the studies in the review used doses of ROC less than 0.9 mg/kg (most studies used 0.6mg/kg).

Dr. Strayer asserted that ROC’s onset of action is dose dependent; when using doses of 1.2 mg/kg, ROC’s onset is indistinguishable from that of SUC. He also stated another major benefit of ROC is the lack of adverse effects that SUC possesses (hyperkalemia and malignant hyperthermia).

What are your thoughts on this? Go to http://www.facebook.com/Criticalcarenow and take the poll (there are 5 choices). Results will be posted next week.

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Question

56 year-old male presents with chest pain. You perform an ultrasound of the heart and see the clip below. What's the diagnosis? Thanks to Dr. Ken Butler for the case.

 

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Question

36 year-old female presents with left knee-pain following a motor vehicle crash (XRs are shown). What's the diagnosis AND what is the first test that should be performed to assess for vascular injury?

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