Trick of the Trade: Difficult intubation — making lemonade out of lemons

In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.

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By Michelle Lin, MD|2016-11-11T18:51:16-08:00Jan 31, 2012|Tricks of the Trade|

Paucis Verbis: Pediatric fever without a source (Birth-28 days)

Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient’s age. Today’s PV card focuses on the youngest age group: Birth-to-28 days.

QUESTION to everyone:

Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I’ve seen varying practices.

PV Card: Pediatric Fever Without a Source (Birth-28 Days Old)

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Go to ALiEM (PV) Cards for more resources.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

By Michelle Lin, MD|2021-10-11T15:15:20-07:00Jan 27, 2012|ALiEM Cards, Pediatrics|

Trick of the Trade: Minimizing propofol injection pain

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz…

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection?

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By Michelle Lin, MD|2019-01-28T22:23:58-08:00Jan 24, 2012|Tox & Medications, Tricks of the Trade|

Paucis Verbis: Antibiotics and open fractures

$Fx Tib Fib Open Irrigation open fractures antibiotics$

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.

Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?

Pearl

Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside.

PV Card: Open Fractures and Antibiotics

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

Reference

Hoff W, Bonadies J, Cachecho R, Dorlac W. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751-754. [PubMed]

By Michelle Lin, MD|2021-10-11T15:20:36-07:00Jan 20, 2012|ALiEM Cards, Orthopedic|

Paucis Verbis card: Interpretation of intraosseous blood

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

PV Card: Interpreting Labs from the IO Line

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

Thanks to Dr. Michael McGonigal at Trauma Professional’s Blog for posting about this.

Reference

Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. [PubMed]

By Michelle Lin, MD|2021-10-11T15:23:29-07:00Jan 13, 2012|ALiEM Cards, Heme-Oncology|

Trick of the Trade: A removable guidewire

An essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used elsewhere. For instance, what’s your go-to approach when looking for a spare guidewire? Let’s say you are trying to salvage an ultrasound-guided basilic vein IV catheterization.

Here’s where I go for guidewires:

Central line kits
Pneumothorax pigtail kits
Seldinger-based cricothyrotomy kits

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By Michelle Lin, MD|2016-11-11T18:51:26-08:00Jan 10, 2012|Tricks of the Trade|

Blog Incubator Experiment: Be the next big thing in blogging

There are many health and technology incubators out there, which help to build start-up companies into thriving and profitable organizations.

Why can’t we do this for those who are thinking about starting a blog? In 2009 when I was thinking about starting the blog, I had lots of support and encouragement. I slowly grew my readership by word-of-mouth and things really got going when the folks over at Life in the Fast Lane, Poison Review, EMCrit, and so many more graciously pointed their readers toward my site.

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By Michelle Lin, MD|2017-03-05T14:18:34-08:00Jan 7, 2012|Social Media & Tech|

About Michelle Lin, MD

PV Card: Pediatric Fever Without a Source (Birth-28 Days Old)

Pearl

PV Card: Open Fractures and Antibiotics

Reference

PV Card: Interpreting Labs from the IO Line

Reference