Alarms from the ventilator: Troubleshooting high peak pressures

Airway management is one of the defining skills of an emergency physician, but our role in the care of intubated patients may continue long after endotracheal tube placement is confirmed. In mechanically ventilated patients, acute elevations in airways pressures can be triggered by both benign and life-threatening causes. When the ventilator alarms, do you know how to tell the difference? What is your approach in troubleshooting the potential problems?

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By Todd A. Seigel, MD|2019-04-06T00:36:46-07:00Jul 30, 2013|Critical Care/ Resus, Expert Peer Reviewed (Clinical)|

Supraventricular Tachycardia (SVT) With Aberrancy Versus Ventricular Tachycardia (VT)

Differentiating between SVT with aberrancy and VT can be very difficult. It is crucial to be able to make this distinction as therapeutic decisions are anchored to this differentiation. Brugada et al prospectively analyzed 384 patients with VT and 170 patients with SVT with aberrant conduction to see if it was possible to come up with a simple criteria to help differentiate between the two with high sensitivity and specificity.

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By Salim Rezaie, MD|2019-09-10T13:36:56-07:00Jul 23, 2013|Cardiovascular, ECG, Expert Peer Reviewed (Clinical)|

EKG Subtlety: Tall T-Wave in Lead V1

EKGs are a simple, cheap modality that can give an emergency physician quite a bit of information. Sometimes, in a busy ER, this information can be very subtle and almost overlooked without a second thought. A perfect example of this is a New Tall T-wave in lead V1 (NTTV1). This finding can be a normal variant, but can also be a precursor to badness.

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By Salim Rezaie, MD|2019-09-10T13:37:03-07:00Jul 17, 2013|Cardiovascular, ECG, Expert Peer Reviewed (Clinical)|

Trick of the Trade: Urine pregnancy test without urine

A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis. The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago – so no urine now.

Trick of the Trade

Apply several drops of whole blood (instead of urine) into the pregnancy test cassette. In the photo below, the patient was pregnant with a serum beta-HCG level of 250 mIU/mL whose urine and whole blood qualitative tests were both positive.

Did you know that most urine pregnancy test kits are approved for both urine and serum samples? On a quick Google search, I found that Accutest, Cardinal Health, ICON, OSOM, and Rapid Response all are approved for both. The question is whether this will work for whole blood.

One study ¹ in the Journal of Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at exactly this issue. Whole blood pregnancy test performed extremely well, especially if positive:

Sensitivity 95.8%
Specificity 100%
Negative predictive value 97.9%
Positive predictive value 100%

In their study, very low beta-HCG values (<159 mIU/mL) occasionally yielded a false negative for whole blood pregnancy tests. The whole blood testing approach missed a total 9 of 425 pregnancies. Interestingly, the urine pregnancy test was also negative in 5 of those 9 and not performed in the other 4.

Bottom Line

Believe a positive test. Confirm all tests with a urine qualitative test or quantitative serum beta-HCG.

Tip

Be sure to wait at least 5 minutes when using whole blood in the kit. It sometimes takes a while.
Do not apply additional drops of water or saline to the whole blood sample. This causes unnecessary dilution. Just wait for the blood to osmose across the entire test strip.
This is trick is ONLY for medical professionals and not the lay public. We are discussing an actual blood draw and not a simple cut on a finger to obtain blood.

Another example courtesy of Dr. Joe Habboushe (New York Hospital–Queens of Cornell University) and Dr. Graham Walker (Stanford) ² :

S = Sample well; T = Test specific (will show bar if +HCG); C = Control (will always have a bar)

References

Fromm C, Likourezos A, Haines L, Khan A, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012;43(3):478-482. [PubMed]
Habboushe J, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med. 2011;29(7):840.e3-4. [PubMed]

By Michelle Lin, MD|2020-12-04T13:15:41-08:00Apr 10, 2012|Expert Peer Reviewed (Clinical), Ob/Gyn, Tricks of the Trade|