Patwari Academy videos: Primary and secondary assessment

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.

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By Michelle Lin, MD|2016-10-26T17:05:06-07:00Jan 6, 2013|Patwari Videos, Trauma|

Paucis Verbis: Composition of intravenous fluids

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.

PV Card: IV Fluid Formations

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Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Update 1/4/13

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.

Reference

Yunos N, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-1572. [PubMed]

By Michelle Lin, MD|2021-10-08T09:49:07-07:00Jan 3, 2013|ALiEM Cards, Tox & Medications|

New video series: P-Videos by Dr. Jeremy Faust

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…)

By Michelle Lin, MD|2019-09-10T14:03:38-07:00Jan 2, 2013|Life|

MIA 2012: Smith SW et al. Diagnosis of ST-Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. Ann Emerg Med. 2012 Dec;60(6):766-76

Bottom Line

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By Michelle Lin, MD|2016-11-11T18:42:23-08:00Jan 1, 2013|Cardiovascular, ECG|

MIA 2012: Levy P et al. Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department. Ann Emerg Med. 2012 Oct;60(4):467-74.e1.

Bottom Line¹

In asymptomatic black patients who presented to the ED with elevated blood pressure, subclinical hypertensive heart disease was detected in 9 of every 10 patients.

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By Michelle Lin, MD|2016-11-11T18:42:23-08:00Jan 1, 2013|Cardiovascular|

MIA 2012: Canto JG et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012 Feb 22;307(8):813-22.

Bottom Line ¹

Chest pain free MI is a very real phenomenon and it is associated with higher mortality – especially in younger women (NRMI study).

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By Michelle Lin, MD|2016-11-11T18:42:23-08:00Jan 1, 2013|Cardiovascular|

MIA 2012: Campagna JD, et al. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med. 2012 May;42(5):612-20

Bottom Line ¹

For patients with penicillin (PCN) allergies, it is safe to administer third- and fourth-generation cephalosporins (CPN) with no fear of cross reaction.
Use of first- and second-generation CPN should only be avoided when the penicillin antibiotic shares structurally similar R1 side chains.

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By Michelle Lin, MD|2016-11-11T18:42:23-08:00Jan 1, 2013|Tox & Medications|

About Michelle Lin, MD

PV Card: IV Fluid Formations

Update 1/4/13

Reference

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