tag:blogger.com,1999:blog-42886736733658385242024-03-24T23:09:26.447-07:00Procedures Club"Because the only thing keeping you from doing a procedure is not having the courage to do it."John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.comBlogger22125tag:blogger.com,1999:blog-4288673673365838524.post-62626539253554872752015-07-25T05:19:00.001-07:002015-07-25T05:19:37.429-07:00Ultrasound Guided Nerve Blocks, Part Two: The Interscalene BlockRound two.....FIGHT!<br />
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Let's say you have a young, otherwise healthy patient who took a little spill after having a few cold ones, and now he/she has a significant painful deformity in their right shoulder. They cannot touch their contralateral shoulder, not even close. You check a Y-View and you see a classic anterior dislocation. Unless you want to do Civil War medicine, you need to get them relaxed for the reduction. Again, procedural sedation is fun, but it is time and resource consuming, and not without risk. Intraarticular injections can be helpful (and kind of fun!), but they don't result in success 100% of the time. THERE HAS TO BE A BETTER WAY!<br />
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Sorry, I figured that probably wasn't funny the first time. But again, our friends in the world of anesthesia have had a better weapon in their armamentarium for some time now. And that weapon is the interscalene block. If it works in the OR, why can't it work for us?<br />
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When you do one of these, you will preferentially knock out the trunks of C5 through C7. This will cover the shoulder and proximal upper extremity while leaving the medial arm and hand intact. Get set up essentially as if you are about to place a central line in the internal jugular (if you want to see our posts on doing IJ's blind, click here). Visualize the IJ and the carotid as you usually do, and then keep moving laterally until you see the muscle bellies of the anterior and middle scalenes. The trunks should be seen between these bellies. They do look a lot like vessels, so it's always safe to use your doppler to differentiate them.<br />
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Advance your 20 G spinal needle away from your probe, injecting anywhere from 10-20 cc of bupivicaine (or lidocaine) into the potential space. <span style="background-color: white; color: #212121; line-height: 19.7999992370605px;"><span style="font-family: inherit;">Don’t overshoot on your anesthetic volume – too much can overflow into the potential space anterior to the anterior scalene muscle, where the phrenic nerve lies. The easiest way to accomplish this is to cover your targeted nerve trunks in a pattern, in small aliquots so that you surround the nerves concentrically. You should start seeing effects after about 15-20 minutes.</span></span><br />
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Here's yet again another great demonstration from the people at SonoSite:<br />
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Per the usz, these writings are for EDUCATIONAL PURPOSES ONLY. If you recklessly try one of these and drop a lung, it's on you, mon frere, not us. Keep safe, we'll talk more about blocks soon!<br />
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jps<br />
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References<br />
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<span style="font-family: Times, 'Times New Roman', serif;">Roberts and Hedges Clinical Procedures in Emergency Medicine. Saunders 2014, Chapter 31</span><br />
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Blaivas, M., & Lyon, M. (2006). Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. <i>The American Journal of Emergency Medicine</i>, <i>24</i>(3), 293–296. doi:10.1016/j.ajem.2005.10.004</div>
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SonoSite YouTube PageJohn P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com3tag:blogger.com,1999:blog-4288673673365838524.post-20638669463625465442015-06-16T07:55:00.006-07:002015-07-14T12:50:41.913-07:00Ultrasound Guided Nerve Blocks, Part One: The Femoral Nerve Block<div class="separator" style="clear: both; text-align: center;">
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Hey Clubhouse! Sorry we've been out of the loop lately. We all just flew back in from San Diego, and boy are our arms tired.<br />
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One of our beloved colleagues from the community has recently declared to us his love of ultrasound guided nerve blocks--a skill that is established in the anesthesia world but is quickly gaining traction in our realm. Some programs are training their residents in this skill, and some aren't. But we've been inspired to talk about it! That said we will now be featuring a series of posts on this very subject. Our inaugural post today: <u>femoral</u> <u>nerve</u> <u>blocks</u>.<br />
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Let's say we do a little time warp, and we are unfortunately six months into the past, stuck in the dredges of frigid winter. EMS appears with a patient who just wiped out big time on the ice. He's gripping his thigh with his hands, and he is screaming. Maybe he's broken his hip? Maybe it's dislocated? Maybe he cracked the shaft of his femur? For this exercise, let's say that it doesn't matter.<br />
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What does matter is that it looks like this might need a little pushing and pulling, either to get it reduced or maybe just for re-positioning for imaging. Procedural sedation? I mean, we're always down for that, but is there a better way?<br />
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Turns out there is! Specifically we will discuss the femoral 3-in-1 block--so titled as it knocks out the lateral cutaneous, obturator, and femoral nerves. This will completely anesthetize the femoral shaft, with some coverage of the proximal end of the femur. This can be done blind, but adding U/S greatly increases the chance of success--the evidence that's out there has shown that using a probe gets you blockade faster and has a higher rate of complete blockade.<br />
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You'll need the following for your setup: an U/S machine with a linear probe, a 21 G spinal needle, a vial of 0.5% bupivacaine, sterile gloves, a sterile probe cover, and sterile gel. <br />
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Essentially your goal is to infiltrate the fascial sheath, allowing for the rapid distribution of anesthetic to the above mentioned nerves. And to properly do this procedure, you'll need a LOT of local anesthetic--our sources recommend up to 30 mL of bupivacaine.<br />
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When done blind, to confirm you'll either feel a gratifying "pop", your patient will get a paresthesia, or you will feel the pulsations of the femoral artery pushing your needle laterally. But we can do it better! For this jobby, prep and drape the area. Place your probe per convention in the transverse plane, starting at the inguinal ligament. Slide down until you can see the femoral vein and artery (about 2 cm caudad). You shouldn't miss these guys. Just lateral to them is the femoral nerve, which appears as a hyperechoic triangular structure.<br />
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Make a wheal for entry just lateral to the probe. Then go in with your spinal needle directed medially at a 30 degree angle. Get your tip as close as possible to the nerve, and then inject (well, after aspirating first, of course). You should see the local anesthetic spread the tissues in a cephalad direction. You'll want to hold pressure distally during all of this, and then 5 minutes after injection.</div>
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Here's a demonstration from the fine people at SonoSite:</div>
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Here's the usual video (with the usual hilarity) from Whit Fisher:<br />
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As always, these posts are for EDUCATIONAL PURPOSES ONLY. These nerve blocks have the potential to be huge for us as emergentologists, but don't take our word for it. Do your research, and always be safe.<br />
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jps/bmc<br />
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Sources:<br />
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<span style="font-family: Times, 'Times New Roman', serif;">Roberts and Hedges Clinical Procedures in Emergency Medicine. Saunders 2014, Chapter 31</span><br />
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Beaudoin, F. L., Haran, J. P., & Liebmann, O. (2013). A Comparison of Ultrasound-guided Three-in-one Femoral Nerve Block Versus Parenteral Opioids Alone for Analgesia in Emergency Department Patients With Hip Fractures: A Randomized Controlled Trial. <i>Academic Emergency Medicine</i>, <i>20</i>(6), 584–591. doi:10.1111/acem.12154<br />
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Cristos, S., Chiampas, G, Offman, R, & Rifenburg, R. (2010). Ultrasound-Guided Three-In-One Nerve Block for Femur Fractures. <i>Western Journal of Emergency Medicine</i>. 11(4), 310-313</div>
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Turner, A. L., Stevenson, M. D., & Cross, K. P. (2014). Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. <i>Pediatric Emergency Care</i>, <i>30</i>(4), 227–229. </div>
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Reid, N., Stella, J., Ryan, M., & Ragg, M. (2009). Use of ultrasound to facilitate accurate femoral nerve block in the emergency department. <i>Emergency Medicine Australasia</i>, <i>21</i>(2), 124–130. doi:10.1111/j.1742-6723.2009.01163.xdoi:10.1097/PEC.0000000000000101</div>
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Fletcher, A. K., Rigby, A. S., & Heyes, F. L. P. (2003). Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial. <i>Annals of Emergency Medicine</i>, <i>41</i>(2), 227–233. doi:10.1067/mem.2003.51<br />
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SonoSite YouTube Page</div>
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<span style="font-family: Times, 'Times New Roman', serif;">Whit Fisher's YouTube Page</span>John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com3tag:blogger.com,1999:blog-4288673673365838524.post-27507232856347582122015-04-16T19:06:00.002-07:002015-04-16T19:06:27.928-07:00Small Joint Arthrocentesis.....VIDEO!After a long, long wait, Procedures Club Videos are finally here! This month, we present the perpetual challenge of Small Joint Arthrocentesis (specifically the wrist, the elbow, and the ankle). This has been in the making for some time now, and we're very proud to finally present it. It's been a pilot production for us--we learned a lot about making these on the fly. The whole dealie-o has been an inspiration for bigger and better content in the future. So enjoy, but as always remember that these are for EDUCATIONAL PURPOSES ONLY. Don't go tapping like a madman because some guy on the internet told you so.<br />
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And yes, we know, John's head is really freaking huge.<br />
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<iframe allowfullscreen="" frameborder="0" height="281" mozallowfullscreen="" src="https://player.vimeo.com/video/125208991" webkitallowfullscreen="" width="500"></iframe> <br />
<a href="https://vimeo.com/125208991">Small Joint Arthrocentesis</a> from <a href="https://vimeo.com/user39346185">Procedures Club</a> on <a href="https://vimeo.com/">Vimeo</a>.John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-4327263413357121012015-04-06T19:46:00.002-07:002015-04-09T22:03:15.064-07:00Priapism!Let's say you're sitting in your shop when a sharply dressed fifty-somethingish gentleman shuffles in looking very uncomfortable, but also a bit embarrassed. You take your high quality history, and you reveal that he's been using a product known as "Triple Mix", which is a combination of paparavine, phentolamine, and prostaglandin--formulated for the treatment of erectile dysfunction. And specifically, it's meant to be injected into the penis (and amazingly it's FDA approved!).<br>
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You discover that he last used said product eight hours ago, and while the treatment was very effective, his erection hasn't gone away, he's now experiencing some pretty significant pain. You examine him and discover a gloriously tumescent penis. Diagnosis? Priapism! Better get yer gloves on.<br>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNTA459XltApWDZbXAytiDwTTT0L1UWBzuEOxQ6MFWRwOzeb03YGYL3sgPhbC7c1Bn_RPNAn6CusyF34FUn_mgkllMWY-u-cv2Alb9LBI2HNLk3k6LSySze1lOWiqYXQ6ekWyFrDp_hso/s1600/unnamed.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNTA459XltApWDZbXAytiDwTTT0L1UWBzuEOxQ6MFWRwOzeb03YGYL3sgPhbC7c1Bn_RPNAn6CusyF34FUn_mgkllMWY-u-cv2Alb9LBI2HNLk3k6LSySze1lOWiqYXQ6ekWyFrDp_hso/s1600/unnamed.png" height="170" width="400"></a></div>
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Before we do anything, let's start with some basic science review. The erectile tissue of the penis is composed of the cavernosal arteries (the "eyes" of the diagram above), which sit inside the corpora (plural!) cavernosa. An erection occurs when the cavernosal arteries engorge the cavernosa. In normal physiology, this tapers off as cavernosal pressure approaches arterial pressure, until the neuroendocrine system ultimately switches it all off. The blood then drains back out via the emissary veins.<br>
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In <i>low-flow</i> priapism (the most common variety), the drainage mechanism gets stuck. this can be caused by compression of the emissary veins (as in iatrogenic cases), venous blockage (seen in sickle cell anemia, leukemia, coagulopathies), or neurohormonal dysregulation (also usually iatrogenic). The far rarer <i>high-flow</i> priapism is caused by uninhibited arterial inflow, and occurs almost exclusively in trauma. Clinically, the hallmark of priapism is a painful erection lasting for several hours in which the glans remains soft and spongy whilst the corpora remains tumescent.<br>
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This can make your patients pretty uncomfortable! What's more concerning is that the priapism can potentially result in ischemia from sludging and clotting in the cavernosa. Irreversible impotence is another possibility. So yeah, it's an emergency, and uh, yeah, you've gotta drain it now.<br>
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As it turns out, the procedure is not terribly difficult. You can break it down into a few steps:<br>
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<li>Start with a warm sitz bath to help dilate the emissary veins and facilitate drainage. At least, this is what Rosen's recommends we start with. Usually pretty futile but it doesn't hurt to try.</li>
<li>Try peripherally dosing a peripheral vasodilator like terbutaline or hydralazine. These have been quoted as having "variable success."</li>
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Once you're ready-</div>
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<li>Anesthetize the area with 1 cc or so of lidocaine (WITHOUT EPI!) at approximately 8 o'clock and 4 o' clocl on the sides of the proximal shaft. This avoids hitting the dorsal neurovascular bundle and the urethra. You also shouldn't have to go very deep. Note that the image above uses 10 o' clock and 2 o' clock, which is also acceptable. Be generous with this stuff!</li>
<li>Using sterile technique, stick butterfly needles into the numbed sites, and attach 10 cc syringes to them--smaller syringes will generate better negative pressure. You should be able to evacuate blood immediately. Even if only one side works, there is communication between the corpora, so just keep aspirating.</li>
<li>You can also simutaneously irrigate through a second butterfly with a prepared solution of 10 mg of phenylephrine diluted in 500 cc of normal saline. This will assist with constriction of cavernosal arteries. If the flow stops or slows, give a flush.</li>
<li>Drain until detumescence. It will be a bloody mess.</li>
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If you get the desired result of detumescence, you should watch your patient for an hour or so to ensure that cavernosal blood doesn't reaccumulate. If they look good after this, the patient can be discharged home with urology follow-up ASAP. If the techniques fail, the patient needs to go to the OR with a urologist--they will need to consider putting in a shunt or excise some clots under anesthesia.</div>
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Dr. Larry Mellick has a great demonstration on his YouTube site here:</div>
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Some parting pearls of wisdom:</div>
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<li>Ancillary techniques have limited success in improving priapism--you probably just need to drain the thing.</li>
<li>Drainage is not rocket science, you just need to be sure to avoid poking the dorsal neurovascular bundle as well as the urethra.</li>
<li>Always be aware of the potential for symptomatic effects of the aforementioned vasoactive substances, especially if the penis is only semi-erect (hint hint -- the emissary veins will carry your phenylephrine downstream).</li>
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And always as always, these writings and musings are for EDUCATIONAL PURPOSES ONLY. Do we really have to remind you to be careful about going at a penis with a needle? Be safe!</div>
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ak/jps</div>
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Sources:</div>
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<span style="font-family: Times, Times New Roman, serif;"><br></span><span style="font-family: Times, Times New Roman, serif;">Rosen's Emergency Medicine, Chapter 174.</span></div>
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The Northwestern Lake Forest Hospital Department of Urologic Surgery<br>
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Dr. Larry Mellick's YouTube Page</div>
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John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-79488975396822545372015-03-14T17:44:00.002-07:002015-03-14T17:44:54.515-07:00Managing a Shoulder Dystocia<div class="separator" style="clear: both; text-align: left;">
Good afternoon, doctor. Are you enjoying your quiet Sunday afternoon shift with this snowstorm outside (just playing odds this year)? That's great. Well, I hate to break up the calm, but I have this patient out here in the waiting room? She says she's like a G8P5 or something, and she's 38 weeks, and she thinks she's in labor? She's in a lot of pain and it appears that her contractions are occurring every minute or so.</div>
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Maybe you have obstetrical capabilities at your hospital or maybe you don't. In this case it doesn't matter as there is no time. You get the patient into the stirrups and have her push. The head starts coming nicely and quickly, but then everything....stops...all...of...a...sudden. It would appear that this large child has become stuck on the pelvic brim, and is "turtling" back into the womb!</div>
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Deliveries in the ED are obviously a rare event, and dystocias are a rarity inside of this rarity (representing about 0.6% to 1.4% of deliveries), but they still happen, and you need to know what to do if you end up with the catcher's mitt.</div>
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First of all, you'll need help. A HELPERR to be exact! </div>
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<span style="text-align: left;"><br class="Apple-interchange-newline" />This is a great mnemonic to run through the initial algorithm. (ALARMER is another good one). But seriously, first step--call for some help. You will need at least two additional pair of hands regardless of how</span></div>
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<span style="text-align: left;">Han Solo you like to be in your shop. On top of that, get someone else on the phone. If there's an obstetrician in house, call them. If there's a neonatologist in house, call them. If there's an anesthesiologist in house....you get the idea. </span></div>
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<span style="text-align: left;">Tell your patient to stop pushing--her Valsalva'ing may potentially worsen the situation so you'll need to take over. Have a look at the perineum--will a quick episiotomy let the baby fall out? The answer is probably not, and it's controversial (some studies have shown that it increases risk for severe perineal trauma), but it's always good to have a look. </span></div>
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The money will likely be in the McRoberts maneuver. Studies have shown that this alone will solve the problem in almost half of cases, so do it right! You'll need an assistant on either side to get the patient's legs back in extreme, extreme super lithotomy to rotate the pubic symphysis superiorally. Have them hyperflex the hips with the knees pushed to the chest.</div>
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Supplement this with suprapubic (not fundal!) pressure directed inferiorally to hopefully push the anterior shoulder out. This is also known as the Mazzanti maneuver--dystocia is just crawling with eponyms. </div>
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If unsuccessful, try rotational maneuvers like the famous Woods' Screw, aka the Rubin Technique. Essentially you'll want to place a finger into the vagina, anterior to the infant's posterior shoulder. Then rotate 180 degrees, like a big old screw in the wall. The reverse Woods' is as expected, and involves the posterior aspect of the shoulder (and theoretically should be more effective).</div>
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Continuing on, you can try to deliver the posterior shoulder by flexing the arm, gripping the humerus (gently and evenly of course) and then sweeping it across the chest and then out the vagina. No luck? We move on to the last "R" of HELPERR, which stands for"roll onto all fours." This refers to the Gaskin maneuver, which utilizes downward traction on the head to allow the posterior shoulder to descend and be delivered. You can also deliver the posterior arm in this position.</div>
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There are a number of remaining last resorts, like fracturing the fetal clavicle, or the ultimate Zavanelli, but they are so incredibly risky and controversial we won't even begin to describe them. </div>
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Here's a very calm (unlike the real thing) demonstration on a model:</div>
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<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://ytimg.googleusercontent.com/vi/jsC9aUzx510/0.jpg" frameborder="0" height="266" src="http://www.youtube.com/embed/jsC9aUzx510?feature=player_embedded" width="320"></iframe></div>
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As always, these posts are for EDUCATIONAL PURPOSES ONLY. If you have to catch a baby and you're in trouble, call for help if it's available. Don't try to be a hero. Seriously.<br />
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Sources:<br />
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del Portal MD, D. A., MD, A. E. H., MD, G. M. V., MD, T. C. C., & MD, J. W. U. (2014). Technical Tips. <i>Journal of Emergency Medicine</i>, <i>46</i>(3), 378–382. doi:10.1016/j.jemermed.2013.08.110<br />
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Gherman, R. B., Goodwin, T. M., Souter, I., Neumann, K., Ouzounian, J. G., & Paul, R. H. (1997). The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it? <i>American Journal of Obstetrics and Gynecology</i>, <i>176</i>(3), 656–661.</div>
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Roberts and Hedges Clinical Procedures in Emergency Medicine, Sixth Edition. Chapter 56.</div>
John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-124865807913202762015-02-12T18:57:00.000-08:002015-02-12T18:59:13.480-08:00Transvenous Pacing - Decoding the BoxLet's say you're in a small shop at about 2 AM. You've got your feet up and you're reading the Sunday Funnies. Suddenly, EMS comes rolling in with a patient with crushing chest pain. Your EKG is done immediately, and while it does not show a STEMI, let's say it shows complete heart block with the rate somewhere in the upper 30's. <br />
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Your local interventionalist/EP is aware and is en route in his Maserati but it's going to be a good 20-30 minutes before he'll arrive. You briefly consider transcutaneous pacing, but when you look back at your nice, cooperative, conscious patient and realize that deep down in your soul you're just not that cruel. Dust off that kit, because it's time to float a pacer, people!<br />
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You might be thinking, "Transvenous pacing? Really? That made the cut?" We've chosen to highlight this procedure as it is, on paper, very straightforward, but IRL (as noted by several practitioners we've talked with) it can be filled with tons of confusing variables and details. True, one could always hit the "EMERGENCY" button when in doubt but we're smart enough to understand this on a more sophisticated level. Despite the haters out there, the evidence is clear that we can insert these just as efficiently and successfully as our colleagues up in the cath lab.<br />
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Before we put anything in your patient, let's do a FREEZE FRAME and look at your generator. There's obviously a few commercially available products out there, but they all essentially have the same settings:</div>
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1.) Rate - How fast do you want them to go? It depends, but generally you want them above their intrinsic rate, or if they're also getting paced transcutaneously, above that. I've heard experts recommend going about 20 beats higher. 80 bpm is usually a safe place to start.</div>
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2.) Output - How much current do you want them to get? These usually run from 0.2 to 20 mA, and you'll want to start with it cranked all the way to 20 to ensure capture. You can adjust this later (and we'll address this again). The Medtronic generator depicted has two settings for output, labelled "A" for atrial and "V" for ventricular. Since we're only going to be tickling the right ventricle in this situation, leave the "A" output at 0 at all times.</div>
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3.) Sensitivity - How well do you want your generator to detect voltage? It's a bit nonintuitive: the lower you set it, the more sensitive it gets. These go from 0.5 mV to 20 mV, so if you set it at 0.5 it will detect voltages down to that level. If it detects a native depolarization at that voltage and it's equal or faster than the rate you program, your pacer will not fire. Usually there's an asyncronous mode that just paces like a honey badger regardless of the intrinsic rhythm--and that's generally the setting you want to start on.</div>
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These things run on batteries, so also make sure they've been replaced recently.</div>
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Now hit the play button so we can insert this guy. We won't go into detail about placing the initial line as this should be obvious, but just remember that you'll need a Cordis in either the right internal jugular or the left subclavian (it's a board question, people!). Get sterile, but you will need a non-sterile colleague to help you when it's time to attach the generator to the cable--unlike most emergency medicine procedures, this will become a two man (or woman) job at this point). </div>
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There are a number of different kinds of catheters you can use here but for the sake of time let's assume you have a flotation catheter. They are placed under ECG guidance and generally are the most appropriate for our realm of practice (I mean do you really want to learn about Swan Ganz catheters???)</div>
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<a href="http://medikasupplies.com/wp-content/uploads/2013/03/tmporary-bipolar-flow-directed-stimulation-catheter.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://medikasupplies.com/wp-content/uploads/2013/03/tmporary-bipolar-flow-directed-stimulation-catheter.jpg" height="203" width="320" /></a></div>
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Thread in your catheter with the balloon down to about 10-12 cm. DON'T FORGET THE SLEEVE! It's very easy to proceed and realize you've forgotten this step once it's too late. Once it's on there it gives you a sterile mechanism to reposition the wire if need be. </div>
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Now, hook this guy up! You will need to have your trusty non-sterile assistant attach your line with adaptors to the connecting cable to the box (which, needless to say, goes in the VENTRICLE port). The line marked "proximal" gets attached to the positive lead. If you have an alligator clamp, the distal lead should be hooked up to lead V1 of your EKG machine. This will put you into exploration mode.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjikNNeourRdxacPyWzKPl9m_-EIU65nKql8KJ-AYL79XvM69NKdLIxcU88nNJ0rHYbYdceF9k4qwvAPhSnIZ1s-hWMn10z4OoKjGSIAhK8U2WQEVsSfFYnI18oEY0xh_GW-8P-CMcgGN0/s1600/transvenous1.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjikNNeourRdxacPyWzKPl9m_-EIU65nKql8KJ-AYL79XvM69NKdLIxcU88nNJ0rHYbYdceF9k4qwvAPhSnIZ1s-hWMn10z4OoKjGSIAhK8U2WQEVsSfFYnI18oEY0xh_GW-8P-CMcgGN0/s1600/transvenous1.JPG" height="320" width="249" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLODb3wkHkzu5G-cEB5mOzDroGYFK_3pZ12yaKE2FuNHdyzEme7ja2zgrdvXN3eZ7e89GnJAId8OnJNXsGVeAxvlTalRMEHwGVb5GLZ3pB4DVvQMBJ0UXoG2rAjVm3nmxpfo8LN_sQCMc/s1600/transvenous2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLODb3wkHkzu5G-cEB5mOzDroGYFK_3pZ12yaKE2FuNHdyzEme7ja2zgrdvXN3eZ7e89GnJAId8OnJNXsGVeAxvlTalRMEHwGVb5GLZ3pB4DVvQMBJ0UXoG2rAjVm3nmxpfo8LN_sQCMc/s1600/transvenous2.JPG" height="320" width="316" /></a></div>
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Now tell your assistant, "BALLOON UP!" and float that sucker! You'll need about 1.5 cc of air into the balloon, and move it downstream quickly. You're looking for a STEMI pattern as the catheter tickles the very arrhythmogenic endocardium of the right ventricle. Ultrasonography will also enhance your experience as you can directly visualize your wire abutting the apex. Once you're there, deflate your balloon, close it off with the stopcock, and then lock your line with your sheath.</div>
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Plug the distal lead back into your box, because it's time to rock and roll. Just like we stated earlier, get your rate at about 80, and then start with your output high. Sensitivity can be asynchronous here. You will need to assess for capture both electrically (QRS complexes that follow the pacer spikes) and mechanically (palpable pulses that correspond to your pacing rhythm). Slowly titrate down your output until you lose capture. It's generally accepted that your output should be about twice the threshold so you consistently get good capture. </div>
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Always get a portable chest x-ray once your done to confirm placement, and to make sure you haven't caused any iatrogenic injury. </div>
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Here's the legendary Dr. Al Sacchetti demonstrating how he sets up his transvenous pacers (I think this is tailored to nurses but it's still great):</div>
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<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://ytimg.googleusercontent.com/vi/GPAXS7FyQHQ/0.jpg" frameborder="0" height="266" src="http://www.youtube.com/embed/GPAXS7FyQHQ?feature=player_embedded" width="320"></iframe></div>
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Here's another video of him placing one in an actual patient:<br />
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Just as always, these writings and musings are for EDUCATIONAL PURPOSES ONLY. Listening to me babble on in no way shape or form makes you the expert at floating these things. Be smart.<br />
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Sources:<br />
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Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 15.<br />
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Aguilera, P. A., Durham, B. A., & Riley, D. A. (2000). Emergency Transvenous Cardiac Pacing Placement Using Ultrasound Guidance. <i>Annals of Emergency Medicine</i>, <i>36</i>(3), 224–227. doi:10.1067/mem.2000.108654</div>
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Birkhahn, R. H., Gaeta, T. J., Tloczkowski, J., Mundy, T., Sharma, M., Bove, J., & Briggs, W. M. (2004). Emergency medicine-trained physicians are proficient in the insertion of transvenous pacemakers. <i>Annals of Emergency Medicine</i>, <i>43</i>(4), 469–474. doi:10.1016/S0196064403010540</div>
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Harrigan, R. A., Chan, T. C., Moonblatt, S., Vilke, G. M., & Ufberg, J. W. (2007). Temporary transvenous pacemaker placement in the Emergency Department. <i>The Journal of Emergency Medicine</i>, <i>32</i>(1), 105–111. doi:10.1016/j.jemermed.2006.05.037</div>
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Al Sacchetti's YouTube Page<br />
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tamingthesru.com<br />
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Life In the Fast Lane.com<br />
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<br />John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-27931757021491158252015-01-19T14:42:00.001-08:002015-01-20T09:43:28.004-08:00The Blind Internal Jugular Central CatheterTo today's young burgeoning emergency physicians, ultrasound guided internal jugular central catheters have more or less become standard of care. And for good reason! They are safe, and after a good amount of experience, quite easy to perform. <br />
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But what if you're practicing in those shops that don't have ultrasound? It's hard to imagine in this day and age but it's the truth in some places. Let's say you're in said department, and a floridly septic patient rolls in. You fluid resuscitate, but after several liters of fluid their blood pressure remains crappier than crappy.<br />
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What's your plan, doctor? You can start that norepinephrine peripherally to buy you some time (bollocks to dopamine of course), but you're going to need central access. Femoral lines are easily done blind, but you'll be unable to get CVP's, and the infection risk limits their lifespan.<br />
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Some of our colleagues who have been in the game more than a few years often quip, "In my day, we did <i>all </i>these blind, you know...." Maybe we should take some advice from our wise forbearers and learn a thing or two.....<br />
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Clearly, your setup will be the same as it always is, with your kit that includes your local anesthetic, finder needle, wire, dilator, scalpel, suture, and catheter. And it's still sterile as humanly possible, of course. To make everyone's life easy, we'll just assume there is no reason you can't use the right IJ and describe the procedure as such.<br />
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Your best friend will be your sternocleidomastoid. Know it like the back of your own sternocleidomastoid! You can access the IJ either anteriorally, centrally, or posteriorally to this landmark. To come at it anterior, find where the medial edge of the SCM meets the clavicle, and measure up 2-3 fingerbreaths. Come in from 30-45 degrees and aim at the nipple. Generally speaking, this approach carries the highest risk of arterial injury.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoWf3YZ5BPXNnOYI_YDg6o786lBe7gwbFNiNKKLZEmW4TDbxpjpP26iSFtI9n74NXcAKMbBsRPdOlHDay7G28oIUsPBVU9f9sjBACokeNPJaxO2bz3pgyYRK0CNfeHb5IIMZ1kQpnxILA/s1600/f022-015-9781455706068.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoWf3YZ5BPXNnOYI_YDg6o786lBe7gwbFNiNKKLZEmW4TDbxpjpP26iSFtI9n74NXcAKMbBsRPdOlHDay7G28oIUsPBVU9f9sjBACokeNPJaxO2bz3pgyYRK0CNfeHb5IIMZ1kQpnxILA/s1600/f022-015-9781455706068.jpg" height="400" width="332" /></a></div>
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To come centrally, identify the triangle formed by the clavicle and the two heads of the SCM. Your needle will enter at the apex of said triangle at an angle of 30 degrees, also aiming at the ipsilateral nipple. </div>
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Finally, the posterior approach brings you higher up in the neck, decreasing the risk of carotid puncture of pneumothorax. You'll need to come about halfway up the lateral edge of the SCM, and come in pretty steep at 45 degrees. Instead of aiming at the nipple, you'll want to come in at the suprasternal notch. Look out for the EJ on your way in!</div>
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The official New England Journal of Medicine video on IJ placement is largely ultrasound driven, but they do have some pretty impressive graphics regarding positioning in an ultrasonagraphically poor world.</div>
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dxvEzZQHy2GtMTlPvK3tNOjumeUARV-wVXVCQakhax22jOHiQ8u6npk2GDD9DPhO9YTRpB2UET99vK1Yeyu' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
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Scott Weingart has a demonstration on the EMCrit blog:</div>
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This is just part of a fantastic piece on central lines that can be found <a href="http://emcrit.org/central-lines/">here</a>. I highly suggest you check it out.<br />
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Just as always, these posts are meant for EDUCATIONAL PURPOSES ONLY. Are you still only comfortable with doing these with a probe? Maybe you should go practice on a model first.<br />
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Stay tuned--Procedures Club Videos are coming to a website near you!<br />
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jps<br />
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Sources:<br />
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Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 22.<br />
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New England Journal of Medicine Videos in Clinical Medicine.<br />
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EMCrit.org<br />
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Life in the Fast Lane Website, Central Venous CathetersJohn P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-57720208169463179782014-12-28T18:04:00.001-08:002014-12-28T18:04:33.440-08:00Escharotomy<div class="separator" style="clear: both; text-align: left;">
After our last post, a few viewers have suggested that we continue the trend of elevated compartment pressures and address a super duper rare yet potentially life saving procedure today. So, escharotomy....here-a we go!</div>
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Let's say you have a patient brought in from a fire with full thickness burns to their torso. You intubate, start hydrating per the Parkland Formula, and you (assuming you are not one) get your burn center on the horn. Your respiratory tech suddenly notes that they are having an incredibly difficult time ventilating patient, and their peak pressures are shooting off the charts. Your trauma surgeon is not readily available, but you need to do something now. </div>
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It's time for escharotomy, as the full thickness burns are causing chest wall constriction. Eschars can also cause peripheral arterial occlusion (not unlike compartment syndrome!), and tracheal compression as well. </div>
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The pressure needs to be released in a fasciotomy-like release, and almost always this should be done in an operating room--if there's time. The procedure itself really does creep outside of the scope of our practice, and really should only be done in absolutely dire circumstances, mainly airway compromise and severe limb ischemia. </div>
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To prepare, you will mainly need some antiseptic prep and a scalpel. It will be handy to have electrocautery (cutting diathermy for the skin and coagulative diathermy for bleeding) available as you may encounter some significant bleeding.</div>
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The incisions to the chest should start at the clavicles at the anterior axillary line and extend inferiorally, down to the subcutaneous fat. You'll want to connect these lines with a transverse incision in the upper abdomen (the so-called "Roman Breast Plate"). If your pressures were significantly elevated you should see notable separation between the wound edges. If it's indicated, extremities can be incised in a similar manner along medial and lateral mid-axial longitudinal lines as depicted below. You'll want to avoid any extensor or flexor creases.</div>
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<a href="http://cdn.lifeinthefastlane.com/wp-content/uploads/2010/03/primary-surgery-escharotomy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://cdn.lifeinthefastlane.com/wp-content/uploads/2010/03/primary-surgery-escharotomy.jpg" height="400" width="245" /></a><br />
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If the burns are full thickness, the skin should be insensate but local anesthesia may be indicated if there's a question if it's partial thickness or not. Overall optional as your patient is hopefully intubated and sedated at this point, and you may not have the time.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxYlfWomqE-st1K2hGQTi9d5PyW7dft0dTX9KX5fnS29j7oMIOfsy0f_zurqet6umMnI8SLC9TpH-jgClKKaCx3K5deKxHb-uA0ESJewk_iZ4rZYoYnMHMpi2IXv479E9O4nL3idmajBY/s1600/escharotomy.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxYlfWomqE-st1K2hGQTi9d5PyW7dft0dTX9KX5fnS29j7oMIOfsy0f_zurqet6umMnI8SLC9TpH-jgClKKaCx3K5deKxHb-uA0ESJewk_iZ4rZYoYnMHMpi2IXv479E9O4nL3idmajBY/s1600/escharotomy.JPG" height="400" width="281" /></a></div>
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A very creative, MacGyver-esque simulation model can be seen <a href="http://sydneyhems.com/2014/08/30/build-your-own-escharotomy-man/">here</a> courtesy of Greater Sydney Area Helicopter Emergency Medical Service.<br />
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As always, these procedures are meant for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. All efforts should be made for this one to be done in a controlled, operative setting with trained sub-specialists, and not in your shop.<br />
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Sources:<br />
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Roberts and Hedges Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 38.<br />
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Life in the Fast Lane Blog - "Releasing the Roman Breastplate"John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com1tag:blogger.com,1999:blog-4288673673365838524.post-54526521971298903232014-12-04T08:00:00.000-08:002014-12-04T08:35:32.742-08:00Compartment Pressure Measurement - "Stryker" It!Let's say you have a middle aged otherwise healthy patient who, after throwing back a few cold brewskis, decides to "kick it" with a group of skateboarding youths. We'll cut to the chase and state that it doesn't go well, he's now in your ED, and his left calf doesn't look too hot. Maybe he's got a tibial fracture, maybe not. Either way his leg is tense as can be, and despite getting an adequate dose of narcotics he is in E-X-Q-U-I-S-I-T-E pain. You do an exam, and note a tense extremity with pain with passive stretch, some decreased sensation, but has a good distal pulse.<br />
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Just like Lloyd Bridges in Airplane, you should be shouting, "Stryker! Stryker! Stryker!" Stryker needle that is (it's the most commonly used product, so we'll only refer to that one), to rule out compartment syndrome.<br />
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The condition can occur in any extremity, but the most common presentation you'll see is the one stated above. It is an incredibly difficult diagnosis to make clinically, and it is a huge potential pitfall as correct identification can be delayed or even missed entirely. An interesting cohort study from the Canadian Journal of Medicine noted that patients at a hospital in Montreal who underwent fasciotomies noted a concerning "median event-to-operation" duration of 9 hours for traumatic cases and a shocking 34 hours for nontraumatic cases.<br />
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We are always taught the classic 5 P's (pain/swelling, pallor, paresthesias, paralysis, pulselessness), but if you're noting these findings the cat is already out of the bag, and your patient will likely have permanent deficits as a result. If it's early, you'll have to trust your gut and go check the pressure.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBIhy5re2I73qnBO1DzZa4JAZvHzOO71L7iYLon2g_y6W_2OIqQoN0RsNu4erWoT-SvPr-cb3Y_PlXR5_16BpZgV0mu0ZZ0JfhDX5JafDT_6DJZZkXeeVCBClW8grlrKA6MBEWDrdPKD0/s1600/2011-compartment-syndrome.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBIhy5re2I73qnBO1DzZa4JAZvHzOO71L7iYLon2g_y6W_2OIqQoN0RsNu4erWoT-SvPr-cb3Y_PlXR5_16BpZgV0mu0ZZ0JfhDX5JafDT_6DJZZkXeeVCBClW8grlrKA6MBEWDrdPKD0/s1600/2011-compartment-syndrome.jpg" height="320" width="248" /></a></div>
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The set-up for this one is pretty simple, and everything you'll need should be in the pre-packaged kit. It includes a side ported needle, a diaphragm chamber, a prefilled 3 cc syringe, and the main monitoring unit. It is possible to jury rig a set-up to continuously transduce pressures like an arterial line, but it's beyond highly unlikely you would ever need to do this in the ED (more tailored for either the OR or a surgical ICU), so we will not cover that today.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBsw6Z_vcmeyyPJitsVpsyyp4dj0KM0g9opP4rzBKQlfyo5t5bT0DKkWf8s1_KmPqZcjF8BzOCKFqCwsnLUEZVJIsrv5Qj2yTEBZk5oCDHD0zZyxQIp0wYR_EanJsG67Vzb1vKxfjNsuw/s1600/678525-fig-001.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBsw6Z_vcmeyyPJitsVpsyyp4dj0KM0g9opP4rzBKQlfyo5t5bT0DKkWf8s1_KmPqZcjF8BzOCKFqCwsnLUEZVJIsrv5Qj2yTEBZk5oCDHD0zZyxQIp0wYR_EanJsG67Vzb1vKxfjNsuw/s1600/678525-fig-001.jpg" height="192" width="320" /></a></div>
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Connect your needle to the diaphragm, and then screw in the syringe on the other side. Load this assembly by pushing it into the monitoring unit, with the black side of the diaphragm down. Snap the cover closed gently. To calibrate, hold the entire unit up at a 45 degree angle, and flush it to get the air out. Push the monitoring button to turn it on, then hold the monitor at the angle you're going to "Stryker at" and hold the zero button down. You should see "00" appear. <br />
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Then you'll need to identify the appropriate site to target. It all depends on where you think the affected compartment is. For sake of discussion, and since it's the most common one, we'll focus on the anterior compartment of the calf. Here, you'll identify the area where the proximal and mid thirds of the tibia meet, and then move 1 cm lateral to this.<br />
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You'll want to give them adequate local anesthesia at the site of injection, but you need to take care not too inject too deeply so that you get a falsely elevated reading. Once this is done and the area has been properly cleaned, insert your needle 1-3 cm into the compartment, and then, very, very slowly inject like an aliquot of saline (they state no more than 0.3 cc) and wait for the reading to appear.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTSOXtCiVd5Q2QoEWkk2Uo1KhfsO3ApF43YqbiVSbOmggcYvWs3oDaHU7L-w5R3RYO4yaqOHzLLYLK0net9mK3xpFivBGZjpuDGSwEWQv4CuepXimjpS55U4uxTpDktFoxQp4po21Cs6w/s1600/compartmentpressure.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTSOXtCiVd5Q2QoEWkk2Uo1KhfsO3ApF43YqbiVSbOmggcYvWs3oDaHU7L-w5R3RYO4yaqOHzLLYLK0net9mK3xpFivBGZjpuDGSwEWQv4CuepXimjpS55U4uxTpDktFoxQp4po21Cs6w/s1600/compartmentpressure.JPG" /></a></div>
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If the pressure is greater than 30 mmHg, or within 30 mmHg of the diastolic blood pressure, your patient needs to be evaluated for a fasciotomy. <br />
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SoBroEm.com also features a nice step by step illustration <a href="http://sobroem.com/2014/04/09/under-pressure/">here</a>.<br />
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Here's another demonstration of the assembly and procedure from the Plastic Surgery Project:<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/ewMD0OUlpqg?feature=player_embedded' frameborder='0'></iframe></div>
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If you haven't had a chance to check out the YouTube page of Dr. Nabil Ebraheim, go NOW. He's a veteran orthopedist with some incredibly high yield videos. Here's his clip on compartment syndrome (goes out of our scope but still a good watch):<br />
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As always, these writings are for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. This is probably one of the least invasive procedures we've covered thus far, but that doesn't mean you should go running into a patient's room to needle their calf.<br />
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Sources:<br />
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Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 54.<br />
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Messina et al. <span style="font-family: Times, Times New Roman, serif;"><span style="background-color: white; line-height: 1.125em;">A human cadaver fascial </span><span class="highlight" style="line-height: 1.125em;">compartment</span><span style="background-color: white; line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">pressure</span><span style="background-color: white; line-height: 1.125em;"> </span><span class="highlight" style="line-height: 1.125em;">measurement</span><span style="background-color: white; line-height: 1.125em;"> </span><span style="background-color: white; line-height: 1.125em;">model. </span><span role="menubar" style="background-color: white; line-height: 15.956525802612305px;"><a abstractlink="yes" alsec="jour" alterm="J Emerg Med." aria-expanded="false" aria-haspopup="true" href="http://www.ncbi.nlm.nih.gov.ezproxy.galter.northwestern.edu/pubmed/23845521#" role="menuitem" style="border-bottom-width: 0px; color: #660066;" title="The Journal of emergency medicine.">J Emerg Med.</a></span><span style="background-color: white; line-height: 15.956525802612305px;"> 2013 Oct;45(4):e127-31. </span></span><br />
<span style="font-family: Times, Times New Roman, serif;"><span style="background-color: white; line-height: 15.956525802612305px;"><br /></span></span>
<span style="font-family: Times, Times New Roman, serif;"><span style="line-height: 15.956525802612305px;">Vaillaincourt C. et al. Quantifying delays in the recognition and </span></span><span style="font-family: Times, 'Times New Roman', serif; line-height: 15.956525802612305px;">management of acute compartment syndrome. </span><span style="font-family: Times, Times New Roman, serif;"><span style="line-height: 15.956525802612305px;"> </span><span role="menubar" style="background-color: white; line-height: 15.956525802612305px;"><a abstractlink="yes" alsec="jour" alterm="CJEM." aria-expanded="false" aria-haspopup="true" href="http://www.ncbi.nlm.nih.gov.ezproxy.galter.northwestern.edu/pubmed/?term=Vaillancourt+C%2C+Shrier+I%2C+Falk+M%2C+et+al%3A+Quantifying+delays#" role="menuitem" style="border-bottom-width: 0px; color: #660066;" title="CJEM.">CJEM.</a></span><span style="background-color: white; line-height: 15.956525802612305px;"> 2001 Jan;3(1):26-30.</span></span><br />
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Dr. Nabil Ebraheim's YouTube Page<br />
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Plastic Surgery Project YouTube Page<br />
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SoBroEm.com<br />
<br />John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-28126511386387843032014-11-27T08:47:00.001-08:002014-11-27T08:48:47.338-08:00Pericardiocentesis<br />
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So let's say you have a patient--maybe they have a history of malignancy or renal failure or lupus or whatever--and the patient's having some trouble. Let's say they're dyspneic and hypotensive, and round out the classic Beck's Triad with some muffled heart sounds and distended neck veins (although only 33% of patients actually have all three of this point of medical masturbation). You astutely throw on your ultrasound on the chest, and you see something that looks like this:</div>
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Let's throw out the typical Procedures Club stem of "you're at a community hospital and there's no specialist around" blah blah blah and cut to the chase. You're doing a pericardiocentesis today!</div>
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But before you do any poking, let's review the basics for a spell. The pericardium is made of two layers, the visceral and parietal pericardia, with the potential pericardial space between them. Physiologically, there should be about 20ish cc's of fluid there for shock absorbancy and lubrication.<br />
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Generally speaking, once you've got about 200 cc of fluid <i>acutely</i> in there, you start to see some systolic dysfunction. Chronically, the space can accommodate quite well due to elasticity of the structures, so you could theoretically see a huge effusion with no symptoms as it has been there a while. Here's a demonstration of how you can fall off the curve, based on animal studies:</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0lvy8JgHRf_S5KtZzY-bvVUj2AR1BGZ3VAkBQUWXLYOqJGbmLmhm6zEQ6uTbkSt1nOGQJK6Uyx6zea_BQTibCdsgMf4XSpHB0GW17Ok-ka2kcMKhfErv-zaXPbfR4x8v8Kl47Au0exIo/s1600/pericardialeffusion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0lvy8JgHRf_S5KtZzY-bvVUj2AR1BGZ3VAkBQUWXLYOqJGbmLmhm6zEQ6uTbkSt1nOGQJK6Uyx6zea_BQTibCdsgMf4XSpHB0GW17Ok-ka2kcMKhfErv-zaXPbfR4x8v8Kl47Au0exIo/s1600/pericardialeffusion.jpg" height="293" width="320" /></a></div>
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Some other things to note: first off, are they stable? If so, you might have enough time to treat what's causing the tamponade as opposed to the tap--i.e. if they're end stage renal, get them to HD. If they're not stable, consider fluid boluses and pressors to buy you some time. You do want to avoid positive pressure ventilation in these cases, however, as this may cause hemodynamic collapse.</div>
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In terms of preparation, you'll more or less need the following: an 18 G spinal needle, a 10 cc syringe, ECG wires with alligator clips, a guidewire, a pigtail catheter, a dilator, a stopcock, local anesthesia, sterile drape and wipes, and your trusty bedside ultrasound. If you're in a pinch, just grab the 18G and the syringe and go go go.</div>
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<span id="goog_1733456933"></span>There are a few ways to approach the pericardium, The standard approach is subxiphoid, with you standing on the patient's right. After prepping and injecting some local anesthesia, you'll need to identify the left xiphocostal angle, and slide down about 1 cm. This will be your entry point, where you'll come in at about 30 degrees, aimed at the left shoulder. As with any other tap, you'll slowly aspirate as you go in. NEVER move the needle in a side to side fashion, as you may lacerate the underlying epicardium. Once you're in, try to get a good 60 cc out. If you've opted to attach your ECG wire, you can see if you hit epicardium by watching the waveform. If you start seeing ST elevations, back up and watch for them to resolve. After that, wire it and place your pigtail for continued drainage in an ICU setting.<br />
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If you have a legit tamponade, even a small amount of aspiration will cause a significant improvement in your patient. Remember, how they showed on Downton Abbey? Dr. Clarkson did that blind, in ONE POKE? That's how they did it back in the day.<br />
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If it's a hemorrhagic tamponade, the traditional teaching is that you can distinguish it from ventricular blood by looking for clot--pericardial blood shouldn't have any due to the fibrinolytic activity. However, this isn't totally reliable as you may just be tapping a brisk bleed. You'll definitely want to check a post procedure CXR to make sure you didn't put any air somewhere air isn't supposed to be.<br />
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If you're doing it blind, cadaveric studies have shown that subxiphoid is probably the safest way to go, although it is not without complications. Here's the (unauthorized?) ATLS version for your perusal:<br />
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If you have an ultrasound, however, you'll want to try a different route. Specifically, you'll take a parasternal long axis view to identify the tamponade. Your needle will be in plane with the probe. The best part about this one is that you can see the effusion decrease in size in real time.<br />
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Academic Life in Emergency Medicine has a featured a fantastic primer on these based on a paper published by Dr. Arun Nagdev from UCSF. If you want to look particularly slick with this one, you can identify the interior mammary artery with your probe and mark the skin so that you don't hit it with your approach.<br />
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I couldn't find a YouTube demonstration of this (which is a bummer as it appears to be awesome), but here is a subxiphoid approach from the Ultrasound Podcast page:</div>
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As always, these writings are for EDUCATIONAL PURPOSES ONLY. Would you want a family member to unnecessarily have a needle shoved in their pericardium by some overzealous scrub because "he always wanted to do one?" Be smart! Talk soon.</div>
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jps</div>
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Sources:<br />
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Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 16.<br />
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<div class="p1">
Loukas, M., Walters, A., Boon, J. M., Welch, T. P., Meiring, J. H., & Abrahams, P. H. (2012). Pericardiocentesis: A clinical anatomy review. <i>Clinical Anatomy</i>, <i>25</i>(7), 872–881. doi:10.1002/ca.22032<br />
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<div class="p1">
MPH, P. C. I. M., & MD, S. L. (2013). Techniques and Procedures. <i>Journal of Emergency Medicine</i>, <i>44</i>(3), 661–662. doi:10.1016/j.jemermed.2012.06.019</div>
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</div>
<div class="p1">
MD, A. N., & MD, D. M. (2013). American Journal of Emergency Medicine. <i>American Journal of Emergency Medicine</i>, <i>31</i>(9), 1424.e5–1424.e9. doi:10.1016/j.ajem.2013.05.021</div>
<br />
Life in the Fast Lane Blog: http://lifeinthefastlane.com/ccc/pericardiocentesis/<br />
<br />
Academic Life in Emergency Medicine Blog: http://www.aliem.com/ultrasound-guided-pericardiocentesis/<br />
<br />
Ultrasound Podcast YouTube Page</div>
John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com1tag:blogger.com,1999:blog-4288673673365838524.post-4634164220167281482014-10-28T09:39:00.003-07:002014-10-28T09:45:51.185-07:00Surgical Airway, Part Two: Pediatric Translaryngeal VentilationAnd we're back! In our last post, we discussed a number of approaches to the surgical airway, including the traditional "scalpel-hook-tube" method, the Seldinger technique, newer methods using bougies, and homemade/DIY/MacGyver approaches (a shout out to ALiEM's Dr. Andy Neill for sharing his study on emergently using Bic Pens!). But what about kids? That's truly a beast of its own, so today is dedicated to our precious we ones.<br />
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Clearly stating the obvious here: emergent pediatric airways are much less frequent than those in the adult world, and fortunately surgical airways in children are exceedingly rare. But you always have to remember that you cannot do a traditional cric on a child. Their cricothyroid membranes are just too small to accommodate an endotracheal tube, and you have an incredible high likelihood of damaging local structures. A paper we've referenced studied neonatal cadavers and found that in general their CTM's were about 2.8 mm tall, in comparison to the 2.0 ETT, which has an external diameter of 3.0 mm.<br />
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The exact cutoff age varies in the literature, anywhere from age five to age twelve. Generally speaking, if there's a kid, put your scalpel down. You could theoretically use this approach for adults as well, but they would require the jet ventilator--simply bagging them through the catheter won't generate adequate tidal volumes, and 15 L/min through the jet probably won't cut it either.<br />
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What you'll need is generally similar to the needle approach for kids: a 14 G angiocath with a 5 cc saline filled syringe (in a pinch, you can get this out of a central line kit), and some sort of adaptor for BVM (if that's your endpoint).<br />
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The big difference now is that you will need a jet ventilator--the system generally includes a hookup to high pressure wall O2 (generally at about 50 psi), tubing, an on-off valve/injector, a regulator, and a Luer lock to attach to your catheter (see below for images). Is this easily located in your shop? Best make sure that it is.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYRpo4lnSuRxLWDs5ZI3zfbrzfMTesaox0xOkWz28aUd_UGQdjJOXXmO_9fXo02rhbiSdIBAETHdxvyCrv_gHtVKadqHKztXajLQAxJxi0zqK029E900oq6aazLIKp-kFNm7XQe59X0nU/s1600/jetventilation.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYRpo4lnSuRxLWDs5ZI3zfbrzfMTesaox0xOkWz28aUd_UGQdjJOXXmO_9fXo02rhbiSdIBAETHdxvyCrv_gHtVKadqHKztXajLQAxJxi0zqK029E900oq6aazLIKp-kFNm7XQe59X0nU/s1600/jetventilation.JPG" height="340" width="400" /></a></div>
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You'll start by identifying the laryngeal prominence, moving inferiorally to locate the CTM. In neonates and smaller children this may be difficult as their laryngeal prominence is not developed. In these instances, start low and move your finger up the tracheal rings until you've found the CTM. After cleaning, aim your needle caudad at about 30-40 degrees. Just like in our previous post, you'll want to aspirate to get air bubbles. And it should aspirate easily--any resistance suggests you're still in soft tissue. If your patient is awake (hopefully not), you can inject lidocaine via the syringe to suppress the cough reflex.<br />
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After that, just advance the catheter, and remove your needle. If you're going to be using a bag, toss on your adaptor (usually a 3 mL syringe MacGyvered into a 7.0 ETT adaptor--seen below), and start squeezing.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHfI17hSLBVgmKkXy2l3h7mTHKhZdby8gj1RunKKWCSkByZkS1MW7iOyP2jpXSrF7EWgujhPVadRaFFUMhNKjq05eiBGE16PzCg_liy0bPfu3eg5kjLWFdmq6p1wuR8g77RDIdcCYs2T8/s1600/setup.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHfI17hSLBVgmKkXy2l3h7mTHKhZdby8gj1RunKKWCSkByZkS1MW7iOyP2jpXSrF7EWgujhPVadRaFFUMhNKjq05eiBGE16PzCg_liy0bPfu3eg5kjLWFdmq6p1wuR8g77RDIdcCYs2T8/s1600/setup.JPG" height="320" width="240" /></a></div>
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One big downside to using the standard angiocath is that it can kink relatively easy. An alternative, if you have it in your shop, is a nonkinking wire catheter, demonstrated here from the Walls text:<br />
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As for jet ventilating, you'll need to attach your apparatus and do some adjustments. To avoid barotrauma, you'll need to reduce the inspiratory pressures to less than 20-30 psi. This is where an expensive commercial device earns it weight in gold--you'll want a device that can reliably and easily do this quickly. You will want to set your flow rate at about 1 L/min per year of age, and then titrate up 1L/min based on how much chest wall movement you're seeing. Your control will either be a handle or a button, with several variations depicted below:<br />
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Due to their small lung volumes, the jet is generally contraindicated in kids younger than five. In these incidences, use the bag, ventilating carefully (but against a lot of resistance!) and with age appropriate equipment. <br />
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And now, here's your gratuitous Whit Fisher MacGyver video--this one features novel ways to jet ventilate when your equipment is not within grasp (along with some absolute ridiculousness):<br />
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As always, these writings on procedurology are for EDUCATIONAL PURPOSES ONLY. Do your own research, keep calm/carry on, and always do the right thing. <i>You</i> are the expert, and <i>you</i> are the one who will save a (young) life.<br />
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Thank you all for following! And thanks again to <a href="http://emcurious.com/">emcurious.com</a>! <br />
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jps<br />
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References:<br />
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<span style="font-family: Times, Times New Roman, serif;">Navsa, N. et al (2005). Dimensions of the neonatal cricothyroid membrane--how feasible is a surgical cricothyroidotomy? Pediatric Anesthesia, 15:402-406.</span><br />
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<span style="font-family: Times, Times New Roman, serif;"><span style="background-color: white; line-height: 15.552000045776367px;">Walls RM, ed. </span><span style="background-color: white; line-height: 15.552000045776367px; margin: 0px; padding: 0px;">Manual of Emergency Airway Management, Section 2.</span></span><br />
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<span style="background-color: white; color: #232323; font-size: 16px; line-height: 25.600000381469727px;"><span style="font-family: Times, Times New Roman, serif;">Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. </span></span><br />
<span style="font-family: Times, Times New Roman, serif;">Chapter 6.</span><br />
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<span style="font-family: Times, Times New Roman, serif;">Whit Fisher's YouTube Page</span>John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-90802894535533221382014-10-24T09:40:00.000-07:002014-10-28T09:42:14.440-07:00Surgical Airway, Part One: CricothyrotomyHey there, super friends! So far, we've managed to settle down into a groove with this whole blog thing with some solid posts about tough, challenging, weirdo, what-the-heck style procedures. Together, we've made our way through thoracotamies, Blakemores, and lateral canthotomies. We're bigger men and women in white as a result. <br />
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So, I think we're ready to tackle the elephant in the room. We're ready to battle Voldemort; we're willing to stop Johnny from "sweeping the leg"; we're going to confront the Emperor, and we will NOT turn to the dark side of the Force. Our archnemesis is calling, and we're not afraid.<br />
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That's right guys, we're doing the cric today. <br />
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Most providers I've talked to can count the number of cric's they've had in their career on one hand, but they remember every single, bloody detail of theirs, and will continue to do so until the day they die. And I'm not being glib there. The cases that lead to crics are always insanely unique; so unique that writing about any of my examples will surely open the medicolegal Pandora's box from hell. I'll abstain.<br />
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Remember your indications, mainly that you cannot oxygenate or ventilate. If you can't get the tube, but you can successfully place something temporary like an LMA, step back for a second. If there's an alternative, take it.<br />
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Anyway, just like many other things in medicine, there is more than one way to skin a cat. We will talk of a few, but not all, of the methods here, starting with the most rudimentary.<br />
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1.) Traditional Cric.<br />
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The motto of this one is: keep it simple, stupid! You need your knife, you need your hook, you need your dilator, and you need some sort of tube (either a nice trach or a sawed off 6.0 ETT). That's it!<br />
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1.) Find the cricothyroid membrane.<br />
2.) Cut skin vertically 2-3cm--get ready for some bleeding to screw up your view!<br />
3.) Cut membrane horizontally.<br />
4.) Get your hook in the superior aspect before you remove your scalpel. Also get someone to hold traction on this!<br />
5.) Get your dilator in laterally and rotate it down 90 degrees (the Trousseau's are kind of counter intuitive--squeezing opens them).<br />
6.) Tube in, cuff up, start bagging.<br />
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In terms of incision the skin, there is a bit of discrepancy between our generally accepted way of doing these and what is done in the surgery world (i.e., vertically vs. horizontally). I personally remember taking ATLS and having an older trauma surgeon laugh hysterically in my face when I demonstrated doing the initial incision vertically on a model. Ignore the haters out there, this is how we do it and that's that.<br />
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Here's a very nice demonstration on a cadaver courtesy of the University of Maryland Department of Emergency Medicine:<br />
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2.) Seldinger Cric (aka "Melkering It").<br />
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I have never seen this one done but I love the sound of it. For one, my fear of a horribly bloody surgical field is alleviated. However, this option requires a good, confident ability to locate the membrane--this might be a problem if there's significant trauma.<br />
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The kits are as simple as you'd want them to be, including your scalpel, wire, 6 mL syringe, 18 G needle w/catheter, cuffed catheter, and dilator.<br />
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Identify your landmarks, and come at the cricothyroid membrane directed 45 degrees caudad. You'll want to have your syringe loaded with a bit of saline so you can confirm entry into the trachea with air bubbles. Thread your catheter, and the rest is just as you'd expect it--wire it, incise it, and then dilate it! Your dilator slides into the catheter, and you'll want to grip them like so as you push them in:</div>
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After you've hubbed it, pull out the dilator and guidewire. You should be good to go. Here's an incredibly dated looking video from Cook Critical Care:<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/q5544hFMfqk?feature=player_embedded' frameborder='0'></iframe></div>
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3.) Bougie Cric.<br />
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It's all the rage! There's a lot of buzz about this one, and rightfully so--some initial data has shown that it is related to higher success rates and less risk of tracheal damage. And it's quicker!<br />
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You need even less for this one. Your kit will include a No. 20 scalpel, a bougie, a 6.0 ETT, and your finger (you could throw in a hook as well but it's not required). <br />
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The procedure: make a horizontal stab with the scalpel at the cricothyroid membrane (yes I realize what I said earlier). Do it all the way through the skin <i>and</i> the membrane. Bluntly dissect down with your finger, keeping it in there. Load the bougie in under your finger. Slide the tube in. Bougie out.<br />
Done!<br />
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Here's some demonstration images majestically taken by AP:<br />
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Here's a demonstration from Darren Braude via Scott Weingart's YouTube page:<br />
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4.) Crazy MacGyver Cric. <br />
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We're entering the world of the unknown on this one, but essentially you resort to this when you're patient is crashing and you essentially have to grab whatever is nearby. <br />
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While I in no way shape or form recommend you try this, the ever brilliant Dr. Whit Fisher has an awesome technique for making a trach needle out of an IV spike (who would have known?):<br />
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Just threw it in for the sheer awesomeness of it all.<br />
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Pick your poison, but get it right. Practice makes perfect, and the more times you can simulate a cric, the more comfortable you will be when your number comes up. Academic Life in Emergency Medicine has a fantastic recipe to make a bleeding model for simulation here: <a href="http://www.aliem.com/simulation-trick-of-the-trade-bleeding-cricothyroidotomy-model/">http://www.aliem.com/simulation-trick-of-the-trade-bleeding-cricothyroidotomy-model/.</a><br />
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As always, these wannabe instruction manuals are made for EDUCATIONAL PURPOSES ONLY. You already know darn well enough that a cric is the last-ditchiest of last-ditch procedures, so don't go getting heroic on us after this one.<br />
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Stay tuned! Next up is the PEDIATRIC surgical airway.....<br />
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jps<br />
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Sources:<br />
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Robers and Hedges' Clinical Procedures in Emergency Medicine.<br />
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<div class="p1">
Makowski, A. L. (2013). A survey of graduating emergency medicine residents' experience with cricothyrotomy. <i>The Western Journal of Emergency Medicine</i>, <i>14</i>(6), 654–661. doi:10.5811/westjem.2013.7.18183<br />
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Hill, C., Reardon, R., Joing, S., Falvey, D., & Miner, J. (2010). Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. <i>Academic Emergency Medicine</i>, <i>17</i>(6), 666–669. doi:10.1111/j.1553-2712.2010.00753.x</div>
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<div class="p1">
Nakstad, A. R., Bredmose, P. P., & Sandberg, M. R. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. <i>Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine</i>, <i>21</i>(1), 1–1. doi:10.1186/1757-7241-21-59</div>
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<br />
University of Maryland Department of EM's YouTube Page<br />
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Procedurettes YouTube Page<br />
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Scott Weingart's YouTube Page<br />
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Airwaycam.com<br />
<br />John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-65686026715383035322014-09-23T10:13:00.002-07:002014-09-23T10:13:19.292-07:00Lateral CanthotomyHere's the scenario: you're a small community ED on a late Sunday morning. Let's say a middle aged gentleman walks in your door, complaining of left eye pain and loss of vision after blunt trauma to the area. Let's say the local Nelson Muntz threw a rock at his face. Haw haw!<br />
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On exam, he has proptosis of this eye, with significant chemosis. His visual acuity is 20/20 in his unaffected eye but is virtually nonexistent in the affected eye (he has light perception but that's about it). He has severe limitation of his extraocular muscles. You order a CT of his orbits, and it reveals a retrobulbar hemorrhage. You grab your TonoPen and check pressures, and it's off the charts. There is no ophthalmologist in house, and it will take up to an hour for him/her to get there. Better get out your scissors, doc, because you're about to do a lateral canthotomy.<br />
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In recent months I've asked multiple providers about which procedures make them squirm and this one often makes it to the top of their lists. In the end it's not a terribly complex procedure, but there's something about cutting around the eyeball that is inherently unsettling.<br />
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However, these patients have a compartment syndrome of the eye (involving the globe, the ophthalmic artery, and the optic nerve), and it is your job at this point to prevent the patient from having permanent vision loss. The setup is minimal and brief, as time = retina in this situation, and if the specialist isn't going to be in for a while you're responsible for this one. The literature suggests that after the initial loss of vision, you have about 120 minutes until the loss is permanent.<br />
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Quickly throw a few cc's of lido with epinephrine into the lateral canthus, and then squeeze it with a hemostat to reduce bleeding. Then snip through the canthus toward the orbital rim. Pull down and locate the inferior crus of the lateral canthal ligament (this is the cantholysis of the procedure, visualized with the cadaver image below). Recheck your IOP at this time--if it's still elevated you can snip the superior crus as well.<br />
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If done properly the lower lid should fall away from the lid margin. Often patients have dramatic improvement in vision but it's possible that this may take longer to return (assuming you've cut in time to save the structures). Just like other facial wounds they tend to heal well without any significant scarring. Regardless, now you'll really need the specialist for a definitive closure.<br />
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Here's a fantastic video courtesy of Dr. Larry Mellick (who is now also following the site!).<br />
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<object class="BLOGGER-youtube-video" classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0" data-thumbnail-src="https://ytimg.googleusercontent.com/vi/bUAagMd_Q8A/0.jpg" height="266" width="320"><param name="movie" value="https://youtube.googleapis.com/v/bUAagMd_Q8A&source=uds" /><param name="bgcolor" value="#FFFFFF" /><param name="allowFullScreen" value="true" /><embed width="320" height="266" src="https://youtube.googleapis.com/v/bUAagMd_Q8A&source=uds" type="application/x-shockwave-flash" allowfullscreen="true"></embed></object></div>
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As always, these posts are for EDUCATIONAL PURPOSES ONLY. Don't go chopping up eyeballs ha-ha-ho-ho after one quick glimpse at this site (also a small prize to anyone who gets the reference I just dropped there).<br />
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Sources: <br />
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Dr. Larry Mellick's YouTube Page<br />
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Robers and Hedges' Clinical Procedures in Emergency Medicine. Chapter 62.<br />
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<br />
<div class="p1">
Ballard, S. R., Enzenauer, R. W., O'Donnell, T., Fleming, J. C., Risk, G., & Waite, A. N. (2009). Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. <i>Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals</i>, <i>9</i>(3), 26–32.</div>
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<div class="p1">
Vassallo, S., Hartstein, M., Howard, D., & Stetz, J. (2002). Traumatic retrobulbar hemorrhage: emergent decompression by lateral canthotomy and cantholysis. <i>Journal of Emergency Medicine</i>, <i>22</i>(3), 251–256.</div>
John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-67074197927869508892014-09-20T17:29:00.002-07:002014-09-20T17:29:41.426-07:00Thank You To EMCurious!<br />
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We're moving on up! Procedures Club is now officially a part of EMCurious.com! Posts both old and new will be released at http://www.emcurious.com/procedures-club/. We'll attempt to get one out every week, although that may be a promise we regret at one point.<br />
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I think we'll at least keep this blog up for the time being, so keep following! Email us at proceduresclub@gmail.com with suggestions, tips, critiques, etc.<br />
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jpsJohn P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-72259081315395879672014-09-15T14:50:00.001-07:002014-09-16T08:36:23.258-07:00The Art of the Pediatric Laceration Repair<br />
So what just rolled in the door, leaving a trail of blood behind? A 26 year old with a stellate laceration to the face after a night of drinking? No problem, he won't even need local anesthesia. A construction worker with a deep laceration down to his forearm muscle bellies? Might take up a big chunk of time, but no big deal, we can throw in a handful of horizontal mattresses. <br />
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What's that now? A 0.5 cm forehead laceration? What's the issue? Why are you so....oh good god...it's....it's....IT'S A TWO YEAR OLD!!?!??!?!<br />
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These seemingly trivial lacerations, often small and on the upper face, invoke true fear and loathing in the largely adult trained EP. We have to sew on a field that's moving and screaming? For god's sake man, I'm a doctor, not a...<br />
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Our friends in the PEM world fortunately have left us with a few hacks to make our lives significantly easier with these kiddos. So let's stand up to our demons and learn a thing or two!<br />
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Before we do anything, let's get this little fella comfortable. Slap on some of that LET we've heard so much about! Wait, does this stuff actually do anything?<br />
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<span id="goog_1829595855"></span><span id="goog_1829595856"></span><br />
An RCT from the Canadian Medical Association Journal in 2013 (n=221) showed that these kids did in fact have less pain with the procedure, and were more likely as compared to placebo (51.6% vs. 28.3%) to have a completely pain-free procedure. In short it often precludes the need for any local anesthesia (because it turns out that kids do not like needles). It also was shown to increase hemostasis. So slather that stuff on, but make sure you wait long enough for it to take effect (about 15-20 min).<br />
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Do you papoose? We sure like to! It is safer for the child in general, as well as it is for us. I've had a kid actually ask me to put him in there before--maybe it made him feel more secure?</div>
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From here on out, distraction is essential. Again, the data supports that things like music, video games, and cartoons can take the child's mind off what you're doing, and help them relax. It'll also take the stress away from what is likely an extremely anxious parent as well. There's a cool iPhone app called "Eye Handbook" that has tons of cartoon animations that kids can fixate on, so you always have something in your pocket.<br />
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Irrigation can also be alarming to the child, but you can employ a cool Macgyver maneuver thanks to the ingenious Dr. Michelle Lin. Essentially you can take a collection bin and cut out a rectangular or semi-circular hold from the edge, leaving enough of a lip so that water doesn't trickle out. You'll want it to look like a hair salon basin. <br />
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Anxiolysis isn't required but it can definitely be your friend. A very popular option is intranasal midazolam, with the dose being between 0.2-0.3 mg/kg. Your max dose will be 5 mg. This plus Thomas the Train on dad's iPad will put your little guy or girl in a zen-like state of serenity.<br />
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Some data has shown that intranasal ketamine (up to 9 mg/kg, go big or home!) can have a high success rate without the use of an IV. However, you're getting into the realm of sedation at this point, not just anxiolysis. My PEM sources are also not a big fan of this one either, so make sure you really do your research and have the appropriate setup (i.e. pulse ox, end tidal CO2, an extra nurse, etc.) if you're going to undergo this.<br />
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In terms of the actual repair, it really just helps to keep it simple. Simple interrupted! You may opt to use the absorbables for superficial closure if the wound is small, and you think removing sutures will be a major headache for the kiddo. Deeper lacs should always make you think of repairing deeper levels with absorbables as the frontalis muscle may be affected. Just remember that you do need to work faster than you're used to with adults, so make sure you get it right on the first try.<br />
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Adhesives like cyanoacrylates can also come in handy in a pinch but you need to ensure that nothing drips down into the eyes of your flailing kiddo if the laceration is on the forehead or eyebrow. You can get around this by placing a little ridge of petroleum jelly inferior to the wound as a barrier. You can also place them in Trendelenberg to limit the amount of drippage. If it does get in the eye, DON'T USE WATER TO IRRIGATE! This might cause the polymerization to accelerate, so you'll actually want to use topical antibiotics like erythromycin (remember, it causes it to break down) instead. And call an ophthalmologist.<br />
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As always, these posts are made for EDUCATIONAL PURPOSES ONLY. Treat each of these children as if they were one of your own!<br />
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jps<br />
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Sources:<br />
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<div class="p1">
Harman, S., Zemek, R., Duncan, M. J., Ying, Y., & Petrcich, W. (2013). Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. <i>CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne</i>, <i>185</i>(13), E629–34. doi:10.1503/cmaj.130269</div>
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Academic Life in Emergency Medicine - "Trick of the Trade: Pediatric Distractors" http://www.aliem.com/trick-of-the-trade-pediatric-distractors/</div>
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Sinha, M. (2006). Evaluation of Nonpharmacologic Methods of Pain and Anxiety Management for Laceration Repair in the Pediatric Emergency Department. <i>Pediatrics</i>, <i>117</i>(4), 1162–1168. doi:10.1542/peds.2005-1100</div>
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Tsze, D. S., Steele, D. W., Machan, J. T., Akhlaghi, F., & Linakis, J. G. (2012). Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. <i>Pediatric Emergency Care</i>, <i>28</i>(8), 767–770. doi:10.1097/PEC.0b013e3182624935</div>
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<br />John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-39255166118741330362014-08-30T21:12:00.001-07:002014-08-31T10:40:21.078-07:00D.P.L. - Going Old School on TraumaBefore we cut to business (no pun intended), a little THANK YOU from our respective peoples, as a few generous tweets have caused our hits to explode in recent days! I promise we will get posts up more frequently to feed the demand. In the meantime, you all can now follow us on Twitter at @proceduresclub! Also, we've created a new email address at <a href="mailto:proceduresclub@gmail.com">proceduresclub@gmail.com</a> for any requests in the future.<br />
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Anyway, back to the matter at hand. Diagnostic. Peritoneal. Lavage. Yes, ok, everyone stop rolling their eyes. I get it. Many (moreso in our community rather than in the trauma world) now call DPL anachronistic with today's Emergency Department access to CT and FAST. And as they should! The test was a boon to trauma surgery when it was introduced in the 1960's but it is non-specific for intraperitoneal bleeding or diaphragmatic injury and insensitive for pneumoperitoneum.<br />
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However, in some cases your modern modalities may fail you. An example might be a patient with evidence of intraperitoneal fluid with no visible solid organ damage (i.e. you suspect CT is not detecting a hollow viscus injury, which is something that should be promptly taken to the OR). Again, we're being honest here, it may not be a procedure that you ever have to do, but that doesn't get you off the hook of knowing it.<br />
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The "dipple" as I've heard it called is actually an aspiration <i>and</i> a lavage if you want to be technically correct in your description. It can be done in a "semi-open" or "closed" technique, but for the purposes of this post we'll only cover the more EM-friendly, Seldinger-esque "closed" maneuver.<br />
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Think of it as a midline paracentesis, although you'll want to use a very small gauge needle. Get sterile as you normally would, and give a generous amount of local anesthesia just inferior to the umbilicus. The ideal entry site is in the midline here, as it is generally avascular, devoid of fat, and adherent to the peritoneum. Once you puncture through, wire it, puncture the skin with a scalpel, and advance a catheter, directing it caudad either to the right or left. Then, attach your tubing and aspirate for gross blood. </div>
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If no gross blood, allow 1 L of either normal saline or Lactated Ringers to run in. You can put a cuff on the bag to speed things up as this may take a while. After it's all in, drop the bag on the floor and let the fluid run back out to gravity. Some opt to roll the patient back and forth before this to make sure the lavage mixes in. You don't need to wait until the entire liter comes back out--700 mL has traditionally been noted as adequate. Send it off to the lab!</div>
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Here is an excellent primer from UCSD's Department of Trauma and Burn:<br />
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In terms of interpretation, let's just make it idiot proof:<br />
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1.) If you get over 10 mL of gross blood (or really any gross blood realistically), that's positive, you're done.<br />
2.) In blunt trauma anywhere except the lower chest, you're positive if your RBC cell count is greater than 100,000.<br />
3.) If there's blunt trauma to the low chest or a GSW, you need to drop that cutoff to 5,000.<br />
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If you did the DPL right, and there is no IPH, you really shouldn't see more than a few hundred RBC's in your sample.<br />
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Just as always, this post is meant to be for EDUCATIONAL PURPOSES ONLY. Be a smart doc, and don't go claiming we told you it was a good idea to "dipple" all of your blunt trauma patients from here on out.<br />
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jps<br />
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Sources:<br />
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Griffin, X. L., & Pullinger, R. (2007). Are Diagnostic Peritoneal Lavage or Focused Abdominal Sonography for Trauma Safe Screening Investigations for Hemodynamically Stable Patients After Blunt Abdominal Trauma? A Review of the Literature. <i>The Journal of Trauma</i>, <i>62</i>(3), 779–784. doi:10.1097/01.ta.0000250493.58701.ad</div>
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MD, Y.-C. W., MD, C.-H. H., MD, C.-Y. F., MD, C.-C. Y., MD, S.-C. W., & MD, R.-J. C. (2012). Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage. <i>American Journal of Emergency Medicine</i>, <i>30</i>(4), 570–573. doi:10.1016/j.ajem.2011.02.014</div>
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Roberts and Hedge's Clinical Procedures in Emergency Medicine. Chapter 43.<br />
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UCSDTraumaBurn's YouTube Page<br />
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John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-35535098800822360162014-08-10T02:59:00.004-07:002014-08-28T15:35:15.678-07:00The Legendary Rectal Foreign Body Retrieval<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Arial, Helvetica, sans-serif;">If you ever want to hear a story about the "good old days" in the ED you should sit down with our former department chair. He's a forty year veteran (i.e. he predates EM training) and has literally seen everything. The other day he was passing through and I asked him point blank, "What's the biggest thing you've pulled out of a patient's rectum?" He sat down, leaned back and without breaking stride he said, "It was a dill pickle. Really got the fella up there. And in my day we didn't use any sedation. All you had was your metal anoscope, and whup, how's yer father--you shoved that thing up there and hoped you could see something." So awesome.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">All chuckles aside, and despite the fact that this is a coveted procedure, we are often left a bit befuddled when these actually do roll in.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Even if they're small, you need to always assume these FB's can perforate so they by definition need to come out. A good history will give you a good understanding of what you're dealing with, although patients may not always be forthcoming with you (for obvious reasons). Your DRE will be vital, as anything low lying will have a much higher chance of being retrieved in the ED. Finally a plain film of the abdomen is a quick and useful test you can order than can give you a lot of information, especially if the patient is being coy with you.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">These situations are great opportunities for us to use our ability to MacGyver devices to our advantage, but some ground rules should be established before we get too cavalier. If the patient is already peritonitic at presentation, stop what you're doing and call surgery as they may have perf'ed already. Do the same if there is glass involved and you're pretty sure that something has shattered.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">If you do decide to go after the FB, you'll need some sort of speculum. A vaginal speculum with a light can actually serve as a decent substitute for an anoscope. Once you have a good view you can try reaching with your bare fingers but a grabbing utensil like a ring forceps may come in handy.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Oh, and you'll need them comfortable as possible, which essentially means procedural sedation. Ketamine will likely make your life a lot easier in these situations. Typically patients are placed prone in a knee-chest position, or in a left lateral decubitus.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Often there's a lot of negative pressure working against you, so you may choose to employ a Foley catheter to pass distally to break this up. An endotracheal tube can also achieve this goal, and it's less likely to bend. Here's an awesome example illustrated by Dr. Whit Fisher:</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">If the FB is a jar or bottle with the open side down, you can employ another neat trick by placing a Foley or ETT into the object, and then injecting Plaster of Paris via the tube. Once it solidifies around the tube, you have a nice handle to pull the object out with.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">As always, these posts are for EDUCATIONAL PURPOSES ONLY. The thought of a rectal FB may make you feel lighthearted and whimsical but you should never, ever treat them as such. Finally, give these patients their dignity--don't be stupid and go posting pictures of their KUB on Instagram once you get home from your shift.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">jps</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Sources:</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Cologne KG et al. Rectal Foreign Bodies: What Is The Current Standard? Clin Colon Rectal Surg. 2012 Dec; 25(4): 214-8. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 45.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Procedurettes YouTube Page</span>John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-65279163661428969892014-07-15T07:33:00.001-07:002014-09-24T10:58:07.569-07:00ED Thoracotomy - A Desperate Procedure For Desperate TimesImagine you're in a large metropolitan area with an uptick in summer gun violence. Let's say you're working an overnight shift on a busy Fourth of July weekend, and your department is already being strained to the limits due to insanely high volumes. Suddenly, at about 3AM, you get a frantic EMS call: a patient is coming to you, shot in the face, chest, and back. He still has vitals in the field and they are currently working on an airway. At our institution, we would instinctively get our trauma bay ready, alert our surgical team, and then all collectively clench our sphincters.<br />
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The patient eventually comes in fast with EMS a bloody mess with GSW's everywhere, yet the paramedics have miraculously been able to place an ETT in the field. He has already received bilateral needle decompressions of his chest. You quickly go to confirming the airway placement with a GlideScope (which, in our opinion, is FAR superior to DL in this scenario), but as the trauma surgeons are running through their primary survey the patient suddenly loses his pulses. <br />
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Suddenly, the knives are out. Before you know it the patient has been "clam-shelled", with bilateral anterolateral thoracotomies. The pericardium is opened, showing tamponade, and the heart is delivered. Shortly thereafter, ROSC is obtained, and the patient was whisked off to the OR.<br />
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Our surgery residents at our institution often do a fantastic job when this procedure is called for, and I am happy we have them around for things like this, but I've realized that we as emergentologists should not be totally exempt from knowing this one. We have tons of attendings in the academic world who have never done one in their careers but I know that in the community, the buck stops with you. So let's learn!<br />
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First of all, you need to remember the indications. Traditionally, we are taught that a patient with penetrating trauma with "signs of life" at the scene who loses them shortly prior to arrival or right at arrival needs to get his/her chest opened. Blunt trauma has more recently been included but has a much lower survival rate (around 2% vs. around 16%). The evidence is spotty at best for both. <br />
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One big disclaimer: this should not always be considered a mandatory procedure. If you're getting a pulseless patient status post GSW's, and the voice in the back of your head is telling you that cracking a chest is overkill (not to mention a giant waste of time to you and all of your staff if there's no surgical backup at your institution), you should probably listen. One should also be aware that the potential for needle/instrument sticks in these scenarios are heightened, so you are also putting yourself and others at risk for something that might be futile.<br />
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However, if you're committed to this route you'll need your kit, which usually includes most if not all of the above. In terms of airway, you'll want to shove the tube down there and deliberately right main-stem the patient so that the left lung can be deflated and moved out of the way.<br />
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Try to get as sterile as possible, but do it FAST. A big splash of betadine on the skin might be all you'll be able to do in terms of prep. In terms of landmarks, go to the same place you'd go for a chest tube (5th intercostal space), and open them up deep with a scalpel and blunt forceps. <br />
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Get the spreaders in there, preferably with the ratchet on the inferior side facing the axilla. Watch your fingers, because it might be sharp! Once inside the thorax, briefly hold ventilations and move the (hopefully) collapsed L lung out of the way and find the heart. Start your pericardiotomy by cutting into the pericardium anterior and parallel to the L phrenic nerve, which should be fairly visible at this point (and stating the obvious--DON'T CUT THE PHRENIC NERVE!). You should lift up with toothed forceps and cut with your Mayo scissors.<br />
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If you'll need to do open cardiac massage/compressions, you can "deliver" the heart from the pericardium to do so. This will also make it easier to visualize any cardiac injuries. In terms of hemorrhage control, you can temporarily use your finger, but you can also place a Foley through as well. For sutures, you can try throwing some buttressed Vicryl throws in there, but you should ultimately leave the definitive repair to the cardiothoracic surgeons (do you really want to try throwing pledgets into a moving field?).<br />
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For cardiac compressions, remember that you want to use your palms, not your fingers. Make sure that you compress perpendicular to the septum, and that you don't compress the coronaries. Also relax completely in between cycles. If there's ROSC but persistent hypotension, you can clamp the descending aorta with a DeBakey or a Kelley clamp but this can be quite challenging even with the chest open as the aorta is often collapsed in these scenarios.<br />
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Here's a very slow, methodical demonstration with a cadaver:</div>
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Here's how it will probably look in your ED (note the stress level is HIGH here):</div>
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Also note that Dr. Mellick is quick to point out that the spreaders are in upside down.</div>
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As always, (and especially for this, the most morbid procedure we can do) these procedure posts are for EDUCATIONAL PURPOSES ONLY! Do your own research and be smart. Cautious always wins over cavalier in the long run.</div>
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jps</div>
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Sources:<br />
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Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J., & Good, A. (2004). Emergency thoracotomy: “how to do it.” <i>Emergency Medicine Journal</i>, <i>22</i>(1), 22–24. doi:10.1136/emj.2003.012963</div>
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Roberts and Hedges' Clinical Procedures in Emergency Medicine. Chapter 18</div>
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Life in the Fastlane - ED Thoracotomy: Is it Just the First Part of the Autopsy? http://lifeinthefastlane.com/ed-thoracotomy-is-it-just-the-first-part-of-the-autopsy/</div>
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University of Maryland EM's YouTube Page</div>
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<br />John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-55633382667065777842014-06-23T12:38:00.000-07:002014-08-28T15:34:06.882-07:00The Blakemore Tube <span style="font-family: Arial, Helvetica, sans-serif;">We EP's pride ourselves on our ability to remain unfazed by a frighteningly unstable patient (a skill that most other specialties do not possess, I'll mind you), but admittedly there is that set of presentations that give even us the chills. I'm talking about the nightmare super-necky angioedema patient that needs a cric, the peri-arrest pregnant woman who's headed toward a crash section, and the spontaneously delivered 24-week preemie who requires an umbilical artery catheter.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">How's about we throw in a cirrhotic with a massively massive variceal bleed into the mix? That's a sphincter flexing sight if there's ever been one. Let's make the scenario a bit spookier by also having no endoscopist available (unlike our tertiary teaching institution). </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Enter the Sengstaken-Blakemore Tube, basically a last ditch effort for balloon tamponade. This procedure is not a common one given the prevalence and efficacy of endoscopy (I honestly don't even know where I'd find one in our ED), but when you're all out of options it's either this or a body bag.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">First, a little clarification. There are two kinds of tubes: the Sengstaken-Blakemore Tube, and The Minnesota Tube. For the longest time I had assumed they were one in the same but they are not. The Blakemore Tube has 3 ports: one for gastric aspiration, one for the gastric balloon, and one for the esophageal balloon. The Minnesota Tube is essentially the same except it has a fourth port for esophageal aspiration. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Before you even begin to insert one of these you almost certainly have to take the airway first--and with a massive bleed this alone will be far from easy. Also, you'll need to make sure both balloons are intact per usual, and then make sure they are completely decompressed before insertion.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">When it's time to pass the tube, you can do it either orally or nasally, but orally is generally preferred. Pass the tube in as far as it can go, and then hook up your aspiration port (s) to suction. You'll need to confirm the placement with a CXR, and some have said that it makes it easier to visualize if you put 50 mL of air into the gastric balloon.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Then, hook up the gastric port to a manometer (doing it with syringes will take too long), and incrementally pump it up to the total volume, which is usually about 450 mL of air (it's a freaking huge balloon, and always use air, not liquid). After this, you'll need to clamp it, pull back until you feel resistance of the diaphragm, and secure with traction.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Start lavaging with the gastric port. If it doesn't clear, inflate the esophageal port as well (which requires much less air, usually only 45 mL). Clamp this one too and monitor the aspiration. If it continues you may need more traction on your gastric port. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Here's Scott Weingart running through the drill with the Blakemore Tube (note his patient is already tubed!).</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">And here's another helpful video from Yale-New Haven Hospital:</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Again, this procedure is almost always a last resort, especially as it is fraught with potential complications, including esophageal rupture (why it's so important to confirm placement of that gigantic gastric balloon), mediastinitis, and aspiration pneumonia to name a few.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Just as always, these posts are meant for medical professionals and are meant for EDUCATIONAL USES ONLY. Do your own research, and be safe. Stay cool out there!</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Sources:</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Greenwald, B. (2004). The Minnesota tube: its use and care in bleeding esophageal and gastric varices. <i>Gastroenterology Nursing : the Official Journal of the Society of Gastroenterology Nurses and Associates</i>, <i>27</i>(5), 212–7</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 41. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Scott Weingart's YouTube Page </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">YNHH Clinical Videos YouTube Page</span></div>
John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-9741013087877705762014-06-03T14:09:00.000-07:002014-08-28T15:34:14.032-07:00The Nasopharyngeal Endoscope - Your New Best Friend<span style="font-family: Arial, Helvetica, sans-serif;">Often we are faced with patients with swollen uvulae (sp??), throat foreign body sensations, etc., and we desperately want to peek into that mysterious land known as the hypopharynx and see what the deal is. Just the other day I had an elderly yet high functioning man come into our shop with the stated chief complaint of, "I feel like there's a grapefruit in my throat!"</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">At our institution--a tertiary teaching hospital--the default is to call ENT to "come down and scope them." However, if you're a DIY-minded emergentologist like us, that doesn't sit right. And why should it? While it has a bit of a learning curve it's a reasonably easy procedure that is definitely within our scope of practice (no pun intended). </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Boring disclaimer: We will <i>not</i> be addressing fiberoptic intubations with this post. That is indeed an incredibly useful skill that despite the demand is not commonly mastered in our field in our time, but we'll tackle that barracuda at a different time.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><span style="font-family: Arial, Helvetica, sans-serif;">To get started, you'll need to collect a few things. Obviously you'll need some sort of flexible endoscope, but you'll also want to get a hold of some 4% lidocaine and an atomizer for local anesthesia. Nebulized lidocaine or 5% cocaine are also options. You'll want to also use Afrin or Neo-Synephrine as an nasal decongestant as well. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">And be liberal with these guys! You want them as comfortable as possible, so also give it time to work (we're talking 10-15 minutes, so go take care of other things for a spell while the meds take effect).</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Allow the patient to sit up with their head free--you need to give them the ability to pull away in case you poke them in a turbinate. You also should be directly in front of the patient to accommodate a smooth passage</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Lubricate the tip, and slowly advance under the inferior turbinate until you get to the soft palate. If you fog up at all, don't worry about a defogger--tapping the tip against mucosa will work just fine. At that point curve down, and after advancing a bit you should have a great view. You should clearly see any FB's or airway compromise. Make sure you see the entire structure, including the piriform sinuses. Check for mobility of the cords while having the patient say, "Eeeeeeee!"</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">When it's time to withdraw, make sure you come out gently, centering on the tissue so that you don't drag at all. Easy, right?!?!? Put it in your toolbox, because this one we can totally handle. However, and just as it is for any other procedure we write about here, this post is for EDUCATIONAL PURPOSES ONLY. Be smart!</span></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><br />jps</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Sources:</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Tom Ashfield's YouTube Page</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 63.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Airwaycam.com</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com1tag:blogger.com,1999:blog-4288673673365838524.post-64256347466354573852014-03-08T03:19:00.000-08:002014-08-28T15:34:36.548-07:00The Bier Block<span style="font-family: Arial, Helvetica, sans-serif;">For fracture reductions in the ED, there are obviously several analgesic options in your armamentarium. There's the tried and true hematoma block, there's sometimes tricky yet potentially rewarding regional nerve blocks, and then there's time and labor intensive but enormously effective moderate sedation. But what about intravenous regional anesthesia, AKA the fabled Bier Block? </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Stop the record for a second, did I just say intra-VENOUS regional anesthesia? You heard me--and surgeons and anesthesiologists have been doing it in the OR for years. Indications also include distal fractures that require reduction, major lacerations, foreign body removal, abscess drainage--pretty much any procedure on distal extremities that hurts like stink. The procedure is simple: the limb is exsanguinated with pneumatic cuffs, and a local anesthetic is pushed as distally in the limb as possible (via a 20 or 22 gauge catheter--the hand is a great place to go). The procedure is performed, and the cuffs are slowly removed. The patient is fully alert but comfortable, and receives no systemic sedation. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Your list of supples are as below, and should be easily obtained in any shop.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Specifically, you dose your lidocaine at 3 mg/kg, injected as a 0.5% saline bolus. You achieve this by mixing it with equal parts saline in a 60 cc syringe. Example: a 70 kg patient would get 210 mg of lidocaine, which would come out to be 21 cc of solution, then mixed with another 21 cc of saline. Then inflate the cuff and attach the Esmarch sequentially as listed above, or just use two separate cuffs. Once you're done, make sure to 1.) Wait until the total on-cuff time is 30 minutes and 2.) cycle the cuff off, slowly deflating for 5 seconds, then re-inflating for 1 to 2 miniutes.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">How safe is this? It sounds frighteningly bold but there has actually never been a recorded case of a mortality, at least from a patient that has had lidocaine as the anesthetic. The only real recognized absolute contraindication is a lidocaine allergy. Relative contraindications include Raynaud's, Buerger's disease, crush injuries, and sickle cell disease (homozygotes).</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The history is quite interesting, dating back to the eponymous August Gustav Bier himself, a surgeon who appeared to be ahead of his time. Surprisingly, the concept arose from the belief from the time that sequestering an infection (in this case tuberculosis) into one extremity via congestion from a tourniquet promoted healing. While testing this wacky hypothesis in 1908 he somehow also came to the conclusion that injected these exsanguinated limbs via venous cutdown with novocaine (the "new" cocaine at the time), he obtained fantastic analgesia that was rapidly reversible.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"> Unfortunately, like several other groundbreaking physicians (Reiter, Wagener, Clara, Seitelberger, etc.) he also happened to be a Nazi. Why'd you have to go there, dude?</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Let's get back from the stone ages here so you can catch Dr. Al Sacchetti performing the procedure. Note that the patient experiences zero pain during the procedure and is fully alert. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Depending where you're at, your nurses may not be a big fan of this, as it does require additional staff and arguably may be more complex and time consuming than regular procedural sedation.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Finally, just as it is for any other procedure we write about here, this post is for educational purposes ONLY. Please do not assume you are a Biermeister Supreme after this and start pushing boluses of lidocaine on people. Be smart.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Sources: </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Zundert, A. et al. Centennial of Intravenous Regional Anesthesia. Bier's Block. (1908-2008). Regional Anesthesia and Pain Medicine. 2008 Sept.-Oct; 33(5): 483-9.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 23.</span></div>
John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0tag:blogger.com,1999:blog-4288673673365838524.post-44345692699189725362014-02-21T09:24:00.001-08:002014-02-21T09:24:59.254-08:00Procedures Club.....Wait For It....Begin!<span style="font-family: Arial, Helvetica, sans-serif;">Welcome proceduralists! My illustrious colleague Dr. Pirotte and I are here to announce our new brainchild, Procedures Club, a blog for emergency physicians, by emergency physicians. We will be covering rarely done but often discussed procedures, obscure procedures, and Macgyver-like maneuvers that impress the youths.</span><div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Just a disclaimer: this site is meant for EDUCATIONAL PURPOSES ONLY, and is intended for medical professionals. Beavis and Butthead copycats, look elsewhere.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Stay tuned, friends.</span></div>
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John P Sarwarkhttp://www.blogger.com/profile/09376773222557131317noreply@blogger.com0