Keywords: anisocoria, pupillary response, pupils (PubMed Search)
Category: Airway Management
Keywords: laryngoscopy (PubMed Search)
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)
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.
Keywords: bedside ultrasound, bedside echocardiography, fluid status (PubMed Search)
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).
Keywords: Splint, Basic, Position (PubMed Search)
Keywords: bladder ultrasound, pediatrics, cathe (PubMed Search)
Bladder ultrasound increases catheterization success in pediatric patients
Keywords: arsenic, diabetes (PubMed Search)
A recent landmark article has cited a connection between non-insulin dependent diabetes and low-level arsenic in our drinking water.
Keywords: cerebral aneurysm, SAH (PubMed Search)
---- 13 to 24 mm --> 14.5 and 18.4%
Keywords: subrachnoid hemorrhageRebeleeding (PubMed Search)
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)
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.
Keywords: cardiac ultrasound, pulmonary embolism (PubMed Search)
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]
Keywords: olecranon, bursitiis, septic, treatment (PubMed Search)
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.
Keywords: Pediatric Intubation (PubMed Search)
In the rush of adrenaline that goes hand in hand with a pediatric intubation often the ETT tip can sometimes be coming out of the little guys toes after passing successfully through the vocal cords, so remember once you get it in and confirm with end-title CO2 detection (capnography or on a monitor) always remember:
Depth of insertion (cm at lip) = 3 x normal size of ETT
Start at this depth, auscultate bilaterally in the axilla to listen for equal breath sounds, and look for equal chest rise. If all are good then secure tube and get your chest xray.
Keywords: cerebral aneurysm, SAH, intracranial bleed (PubMed Search)
Category: Critical Care
Keywords: PRVC, pressure control, volume control, ventilator-induced lung injury (PubMed Search)
Pressure Regulated Volume Control (PRVC)
Keywords: LMWH, PE, Pulmonary Embolism (PubMed Search)
Currently Approved LMWHs for the Treatment of Acute PE:
Make sure to monitor platelet counts regardless of agent chosen.
Konstantinides. Acute pulmonary embolism revisited. Heart. June 2008
Keywords: blunt cardiac trauma, cardiac contusion, myocardial contusion (PubMed Search)
"The most common EKG abnormalities are non-specific ST-T wave changes, followed by RBBB. A normal EKG does not exclude the possibility of cardiac injury, although some investigators report a negative predictive value of up to 80-90%."
[El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med 2008;35:127-133.]
Keywords: Urinary Catheter, Foley, Coude (PubMed Search)
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.
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.
Vilke GM, Ufberg JW, Harrigan RA, Chan TC. Evaluation and treatment of acute urinary retention. J Emerg Med. 2008 Aug;35(2):193-8.
Keywords: drug interactions, disulfiram, bactrim, tinidazole, metronidazole (PubMed Search)
Other common medications that produce this reaction:
1. Sulfonylureas: chlorpropamide, tolbutamide, glyburide
2. Cardiovascular medications: Isosorbide dinitrate, nitroglycerin
Weathermon R, Crabb DW. Alcohol and Medication Interactions. Alcohol Research and Health. 1999 (23);1:40-54.
Keywords: cerebral aneurysms, aneurysm, ACOM, PCOM, SAH (PubMed Search)
--- junction of the anterior communicating artery (ACOM) with the anterior cerebral artery (ACA)
--- junction of the posterior communicating artery (PCOM) with the internal carotid artery (ICA)
--- bifurcation of the middle cerebral artery (MCA)
Singer, et al. "Unruptured Intracranial Aneurysms." November 2007. UptoDate online 16.2.