UMEM Educational Pearls - Procedures

This is a review of the literature surrounding using mechanical compression devices for in-hospital cardiac arrest. The bottom line is there isn’t much evidence to support the use of these devices and there is scant literature in general on this topic. This is an area in need of further research

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• newborns have increased rates of bilirubin production due to RBC's with shorter life spans, and a decreased rate of bilirubin elimination due to decreased ability of the neonatal liver to conjugate bilirubin
• about 60% of newborns will become clinically jaundiced
• bilirubin levels peat at 4 days of life,  and may not decline before day 7
• admission and treatment should be considered urgently when serum total bilirubin >25mg/dL, with exchange transfusion if it is >30mg/dL or the infant has signs of kernicterus
• there are nomograms which plot the bilirubin level according to the infant's age in hours to determine if an infant is at risk for being at toxic levels
• the most common pathologic etiologies are due to increased bilirubin production: blood-group incompatibilities, RBC-enzyme deficiency, and RBC structural defects
• when jaundice occurs between days 4-7, strongly consider sepsis, UTI, congenital infection (syphilis, CMV, etc)

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NG Tubes and Foleys:

Dovetailing off Dr. Hayes Lidocaine pearl on Thursday I thought we could provide an additional pearl on how to decrease pain with the insertion of Foleys and NG tubes.

Most providers use regular surgilube and coat the tip of the NG  tube and foley with it prior to inserting it.  Unfortunately this tends to only lubricate the first several centimeters of the passage you are trying to transverse, making the rest of the way a little uncomfortable.

Using a Uroget of viscious lidocaine allows you to actually inject the lubricant into the nares or urethral meatus.  This will provide better lubrication of the entire passage and also provide some anesthesia.

Even if you do not want to use lidocaine most foley kits come with a syringe full of surgilube that can be injected into the urethral meatus helping to lubricate the passage.

Paracentesis Part II- Ascites Fluid Analysis:

See last weeks procedure pearl for some hints on doing a paracentesis..

Now that you have the fluid what should you send it for:

• Cell Count
• Gram Stain and Culture
• Amylase (normal value is half serum)
• Albumin
• Consider cytology if  cancer is a consideration

Now for the analysis:

• WBC Count >250 PMNs generally accepted as consistent with infection.  Especially if there is more than 70% PMNs which is the upper limit of normal. SAAG (Serum - Ascites Albumin Gradient) an easy calculation to differentiate what the cause of the ascites might be from:
  • Subtract the patient's ascites albumin from the serum albumin (Serum Albumin - Ascites Albumin = SAAG)
  • SAAG > 1.1 mg/dL(Due to items that increase portal pressures)
    • Cirrhosis
    • Alcoholic Hepatitis
    • Cardiac Ascites
    • Hepatic Failure
    • Budd-Chiari Syndrome
    • Portal Vein Thrombosis
    • Myexdema
    • Others
  • SAAG < 1.1 mg/dl (due to intraabdominal forces causing increased oncotic pressure)
    • Tuberculosis Peritonitis
    • Pancreatitic Ascites (typically while have elevated amylase in ascitic fluid)
    • Bowel Obstruction
    • Nephrotic Syndrome
    • Biliary Ascites
    • others

** Corrected definition of SAAG as it was initially reversed.  Thanks to Dr. McCurdy on his proof reading.

Paracentesis:

Since we have covered so many other procedures I though I would include paracentesis for completion.

A diagnostic paracentesis (typically 30-60 ml)  is indicated to:

• Determine etiology of new ascites (transudate vs exudate, cancer, infection)
• Rule out spontaneous bacterial peritionitis...(suspect this in any patient with a history of ascites that has fever, mental status changes, or diffuse abdominal pain)

A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:

• Respiratory distress from abdominal distension
• Abdominal compartment syndrome.  See Dr. Winters Pearl

Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.

Absolute Contraindications to paracentesis include:  Acute abdomen requiring surgery

Relative contraindications are:

• Platelets <20,000
• INR > 2
• Pregnancy
• h/o adhesions
• abdominal wall cellulitis (just don't stick the needle through the cellulitis)
• Distended bowel or bladder

To view a video on how to do a paracentesis please visit the New England Journal of Medicine http://content.nejm.org/cgi/content/short/355/19/e21

Next I will address how to interpret the paracentesis fluid results.

Dental Pain and Blocks:

I am sure that most of us have felt like we should  have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating.  For these patients the only way to truly get their paint under control is to perform a dental block.  This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.

For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html

So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)

 

Placing a foley catheter in a patient with BPH or acute urinary retention can be very difficult at times.  Here are some tips to increase your chance of a successful placement.

1. Use a Uroject lidocaine gel syringe to help anesthesize the urethra and lubricate the tract.  The lidocaine gel should be slowly expressed (injected) into the urethral meatus.  This helps to provide lubrication further down the urethra, as opposed to just wiping the catheter tip in the lubricant.
2. When using a Coude catheter, ensure that the curved tip points upward.
3. Apply gentle continuous pressure to help open the prostrate spincter.  This will be more successful than trying to ram it through which can increase spincter contracture.
4. Do not inflate the balloon until you have confirmed placement with urine return.
5. Don't forget the ultrasound.  You can calculate urinary volume (post void residual) prior to catheter placement and confirm placement with ultrasound.

If all else fails, a suprapubic catheter may need to be placed.  For a great review on evaluation and treatment please see Drs. Vilke, Ufberg, Harrigan, and Chan's article in the August edition of Journal of Emergnecy Medicine entitled Evaluation and treatment of acute urinary retention.

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Most people are now using Ultrasound to aid in cannulation of the femoral and internal jugular veins, but if you find yourself without the ultrasound machine you can increase your chance of successful cannulation of the femoral vein by positioning the leg properly.

Werner et al looked at the common femoral veins of 25 healthy volunteers and noted that the femoral vein was accessable more often when the hip was abducted and external rotated.  This simple position change increased the mean diameter of the vein, and prevented the vein from being directly posterior to the artery.

 

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Lumbar Puncture Pearls On obese patients, it can be easier to obtain a lumbar puncture with the patient in the sitted position. If you require an opening pressure (eg, pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent position

If the CSF flow is too slow, ask the patient to cough or bear down as in the Valsalva maneuver, or intermittently press on the patient s abdomen to increase the flow. The needle can also be rotated 90 degrees such that the bevel faces cephalad.

In children, a recent study has shown that performing an LP can be more successful by using adequate analgesia and advancing the needle through the dura without the stylet.

In adults with suspected meningitis, a CT scan of the head does NOT need to be done prior to the lumbar puncture unless the patient has one of the following

• Immunocompromised state: HIV infection or AIDS, receiving immunosuppressive therapy, or after transplantation
• History of CNS disease: Mass lesion, stroke, or focal infection
• New onset seizure: Within 1 week of presentation;
• Papilledema: Presence of venous pulsations suggests absence of increased intracranial pressure
• Abnormal level of consciousness...
• Focal neurologic deficit

Nigrovic LE et al. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007 Jun; 49:762-71.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267 84.