Doing well on your Emergency Medicine rotation, whether you are a medical student or resident, will depend in large part on your ability to deliver a coherently concise presentation to the senior resident or attending physician. It’s about telling a story that fits into the construct of how the expert physician thinks.
General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video below (automatically starts at 2:25 for the actual procedure). What if this approach doesn’t work? The fracture fragment remains immobile despite your best efforts.
Deer in headlights
That was me as a medical student, when I first encountered an undifferentiated patient in moderate distress. The trick is to have a standardized primary and secondary survey approach. Sometimes it takes just a little kick-start to get you thinking and doing.
There has been a lot of discussion on the ideal intravenous fluids (IVF) for resuscitation in the Emergency Department and ICU. This was highlighted by the landmark study in JAMA on ICU patients who received chloride-rich versus chloride-restricted IVFs. This got me to thinking, what exactly comprises the common IVFs that we order? We so often take for granted what’s in 1 liter of normal saline. As it turns out, normal saline is not really “normal”. Dr. Scott Weingart has a great podcast on “chloride poisoning” using IVFs.
This PV card helps remind me what’s in each liter bag of fluids we order (composition of intravenous fluids). At the bottom half of the card is a brief summary of the JAMA findings.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
After the posting of this PV card, there was intense discussion about why the D5W osmolarity was 252 mOsm/L instead of 272 mOsm/L, which is found on various medical calculators. See the discussion by Dr. Joel Topf.
@kidney_boy @M_Lin @BrianJL @PharmERToxGuy
Great story.
It's not what we know/don't know, it's what we don't know that we don't know.— David Y.T. Chen (@dytcmd) January 4, 2013
Has this JAMA study changed your approach to ED intravenous fluid management?
It sure has for me. After 2 liters of normal saline, I consider switching patients to a more chloride-restrictive fluid (we have Plasma-Lyte in our ED). Examples include patients with DKA, AKA, sepsis, and severe dehydration.
Welcome to the blog Dr. Jeremy Faust, who is currently an emergency medicine resident from Mount Sinai Hospital and Elmhurst Hospital Center. He’s a frequent contributor to ACEP News, a proud proponent of Free Open Access Medical Education (#FOAMed), and a classical musician and producer. We extremely lucky to have Jeremy join our ALiEM blog team.
What are P-Videos? (more…)
Bottom Line1In asymptomatic black patients who presented to the ED with elevated blood pressure, subclinical hypertensive heart disease was detected in 9 of every 10 patients.
