Category: Airway Management
Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)
Posted: 8/27/2008 by Ben Lawner, DO
(Emailed: 9/4/2008)
(Updated: 3/28/2024)
Click here to contact Ben Lawner, DO
To echo Dr. Rogers' fantastic airway tips:
When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:
1. P osition: No intubating on the floor! Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.
2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis.
3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.
4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.
5. P aralysis: This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.
6. P ass the tube: What Dr. Rogers said.
7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.
-Our very own Dr. Ken Butler: "Be prepared!"
Category: Toxicology
Keywords: Lidocaine, pediatrics, anesthesia (PubMed Search)
Posted: 9/4/2008 by Ellen Lemkin, MD, PharmD
(Updated: 3/28/2024)
Click here to contact Ellen Lemkin, MD, PharmD
Topical Lidocaine for local anesthesia
Disclosure: I have no financial or invested interest in the product or the company.
1. Pharmacist's Letter 2008 24(9):240912
2. Cregin R. Improving pain management for pediatric patients undergoing nonurgent painful procedures. ASHSP April 15 2008;Vol 65(8):723-7.
3. Kaweski S. Topical Anesthetic Creams. Plastic and Reconstructive Surgery. June 2008; Vol 121(6):2161-5.
Category: Neurology
Keywords: asterixis, liver failure, elevated ammonia, flapping tremor (PubMed Search)
Posted: 9/3/2008 by Aisha Liferidge, MD
(Updated: 3/28/2024)
Click here to contact Aisha Liferidge, MD
-- azotemia
-- cardon dioxide toxicity
-- metabolic encephalopathies
-- Wilson's Disease
Category: Critical Care
Keywords: sodium bicarbonate, lactic acidosis, hypoperfusion, shock (PubMed Search)
Posted: 9/3/2008 by Mike Winters, MD
(Updated: 3/28/2024)
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Bicarbonate for severe lactic acidosis from shock?
Boyd JH, Walley KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Curr Opin Crit Care 2008;14:379-83.
Category: Cardiology
Keywords: HIV, human immunodeficiency virus, pericardial effusion (PubMed Search)
Posted: 8/31/2008 by Amal Mattu, MD
(Updated: 3/28/2024)
Click here to contact Amal Mattu, MD
Patients with HIV are at increased risk for several cardiovascular complications of the disease. The most common cardiac manifestation in HIV disease is reported to be pericardial effusion.
The presence of a pericardial effusion in HIV is a poor prognostic sign, an independent predictor of mortality (62% mortality at 6 mos is reported, compared to 7% in those without effusion).
The pericardial effusion is often associated with TB in endemic areas, but can also be associated with other organisms including Staph, Strep, Chlamydia, and some viruses. HIV itself can cause an effusion as part of a generalized serous effusive process.
Takeaway: In late-stage HIV patients with any cardiopulmonary complaints, it would be prudent to make bedside ED ECHO part of your usual initial evaluation.
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol 2008;102:635-642. Authors are from Michigan State Univ.]
Category: Gastrointestional
Keywords: HIDA, narcotics, biliary colic (PubMed Search)
Posted: 8/30/2008 by Michael Bond, MD
(Updated: 3/28/2024)
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Biliary Colic and Narcotics:
It is common to give patients with biliary colic narcotics inorder to relieve their pain. It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi. It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.
So this weeks pearls are:
Category: Pediatrics
Posted: 8/30/2008 by Don Van Wie, DO
(Updated: 3/28/2024)
Click here to contact Don Van Wie, DO
Many things can be fatal with only one pill or sip for a young child. One teaspoonful of Oil of wintergreen (5ml) contains about 7000 mg of salicylate (the equivalent of about 21 adult aspirin). It would take only one swallow of Oil of wintergreen to be lethal for a young child.
Other Potential single dose killers for your Pediatric patients:
Alchohols
Methanol
Ethylene glycol
Isopropanol
Antidepressants
Monoamine oxidase inhibitors
Cyclic antidepressants
Antihypertensives
Clonidine
Verapamil
Diltiazem
Antimalarials
Chloroquine
Quinine
Benzocaine
Caustics
Hydrofluoric acid
Ammonia fluoride/bifluoride
Boric acid
Selenious acid
Disk batteries
Herbals
Eucalyptus oil
Pennyroyal oil
Camphor
Oil of wintergreen
Hydrocarbons
Imidazolines
Oxymetazoline
Naphazoline
Xylometazoline
Tetrahydrozoline
Insecticides/Rodenticides/Herbicides
Organophosphates
Carbamates
Lindane
Paraquat
Diquat
Nicotine
Opioids
Diphenoxylate
Methadone
Morphine
Oxycodone
Propoxyphene
Sulfonylureas
Pediatric Emergency Medicine Practice. July 2005.
Category: Toxicology
Keywords: methadone, buprenorphine (PubMed Search)
Posted: 8/28/2008 by Fermin Barrueto, MD
(Updated: 3/28/2024)
Click here to contact Fermin Barrueto, MD
Buprenorphine (Suboxone)
Category: Neurology
Keywords: anisocoria, pupillary response, pupils (PubMed Search)
Posted: 8/27/2008 by Aisha Liferidge, MD
(Updated: 3/28/2024)
Click here to contact Aisha Liferidge, MD
Category: Airway Management
Keywords: laryngoscopy (PubMed Search)
Posted: 8/26/2008 by Rob Rogers, MD
(Updated: 3/28/2024)
Click here to contact Rob Rogers, MD
Quick Pearls for Intubating:
1. When intubating, make sure to use two hands!
2. Resist the urge to look for cords
3. Stylet shape is crucial
1. Our very own Ken Butler
2. Rich Levitan-Airway Course
Category: Critical Care
Keywords: norepinephrine, epinephrine, epinephrine, dopamine, phentolamine (PubMed Search)
Posted: 8/26/2008 by Mike Winters, MD
(Updated: 3/28/2024)
Click here to contact Mike Winters, MD
Phentolamine for vasopressor extravasation
I was recently informed of a case from an another institution in which a patient was started on a vasopressor medication via a peripheral IV while attempts at central access where attempted. The patient unfortunately suffered permanent extremity ischemia due to significant extravasation of the vasopressor medication into the soft tissue.
Category: Cardiology
Keywords: bedside ultrasound, bedside echocardiography, fluid status (PubMed Search)
Posted: 8/24/2008 by Amal Mattu, MD
(Updated: 3/28/2024)
Click here to contact Amal Mattu, MD
The longitudinal subcostal view on bedside ultrasound can be very helpful at addressing a patient's fluid status.
Take a look at the diameter of the IVC 2 cm proximal to the hepatic vein on this view and ask the patient to quickly sniff. If the patient has normal fluid status, the diameter of the IVC will collapse approximately 50%.
If you notice that the IVC completely collapses during the sniff, the finding is highly accurate at predicting hypovolemia and a low CVP.
If, on the other hand, the IVC doesn't appear to collapse much at all, the finding is highly accurate at predicting a high CVP and elevated right atrial pressure. This may occur in the presence of fluid overload from decompensated CHF, cardiac tamponade, and conditions associated with RV failure (e.g. massive pulmonary embolism).
Category: Orthopedics
Keywords: Splint, Basic, Position (PubMed Search)
Posted: 8/23/2008 by Michael Bond, MD
(Updated: 3/28/2024)
Click here to contact Michael Bond, MD
Splinting Pearls:
Category: Pediatrics
Keywords: bladder ultrasound, pediatrics, cathe (PubMed Search)
Posted: 8/23/2008 by Don Van Wie, DO
(Updated: 3/28/2024)
Click here to contact Don Van Wie, DO
Bladder ultrasound increases catheterization success in pediatric patients
Witt M, Baumann BM, McCans K.Acad Emerg Med. 2005 Apr;12(4):371-4.
Category: Toxicology
Keywords: arsenic, diabetes (PubMed Search)
Posted: 8/21/2008 by Fermin Barrueto, MD
(Updated: 3/28/2024)
Click here to contact Fermin Barrueto, MD
A recent landmark article has cited a connection between non-insulin dependent diabetes and low-level arsenic in our drinking water.
Category: Neurology
Keywords: cerebral aneurysm, SAH (PubMed Search)
Posted: 8/20/2008 by Aisha Liferidge, MD
(Updated: 3/28/2024)
Click here to contact Aisha Liferidge, MD
---- 13 to 24 mm --> 14.5 and 18.4%
Category: Vascular
Keywords: subrachnoid hemorrhageRebeleeding (PubMed Search)
Posted: 8/19/2008 by Rob Rogers, MD
(Updated: 3/28/2024)
Click here to contact Rob Rogers, MD
Complications of Subarachnoid Hemorrhage
The three dreaded complications of SAH include the following:
Edlow, et al. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. JEM 2008
Category: Critical Care
Keywords: PEEP, respiratory failure, ventilator associated pneumonia (PubMed Search)
Posted: 8/19/2008 by Mike Winters, MD
(Updated: 3/28/2024)
Click here to contact Mike Winters, MD
PEEP in Nonhypoxemic Respiratory Failure
Manzano F, Fernandez-Mondejar E, Colmenero M, et al. Positive end-expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008;36:2225-2231.
Category: Cardiology
Keywords: cardiac ultrasound, pulmonary embolism (PubMed Search)
Posted: 8/17/2008 by Amal Mattu, MD
(Updated: 3/28/2024)
Click here to contact Amal Mattu, MD
The apical 4-chamber view of the heart on bedside ultrasound gives an excellent comparative view of the sizes of the right ventricle (RV) and left ventricle (LV). The RV is normally ~ 0.5-0.6 the size of the LV. When the RV appears too large, certainly if the RV > LV in size, it indicates RV dilatation.
RV dilatation can be chronic (e.g. COPD or sleep apnea with pulmonary hypertension, etc.) or acute (e.g. PE, RV MI). How can you tell whether the condition is chronic or acute? Just take a look at the RV free wall. If the RV free wall measures < 5 mm, it's a pretty good indication that you are dealing with an acute condition. Think PE or RV MI!
[thanks to Dr. Jim Hwang from Brigham and Women's Hospital for providing this pearl]
Category: Orthopedics
Keywords: olecranon, bursitiis, septic, treatment (PubMed Search)
Posted: 8/17/2008 by Michael Bond, MD
(Updated: 3/28/2024)
Click here to contact Michael Bond, MD
Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna. Can result from trauma, overuse, or infection.
Treatment can consist of:
Remember aspiration has some major risks that need to be explained to the paitent:
They also need to know that the fluid will likely reaccumulate. So aspiration is not a guaranteed cure.