Skin tears are a common injury treated in the elderly in the emergency department (ED). Often the skin is paper thin, and the area involved can have a large flap. By the time the patient has arrived, the may blood have dried with a retracted and rolled-in skin flap. Often the surface area is too big and skin to thin to inject local anesthesia around the entire site.(more…)
The success of adenosine depends as much on the administration technique as it does the mechanism of action. The 2010 Advanced Cardiac Life Support (ACLS) Guidelines recommend the following when administering adenosine:
“6 mg IV as a rapid IV push followed by a 20 mL saline flush; repeat if required as 12 mg IV push”
This recommendation remained in the 2015 iteration.
While most drugs are metabolized in the liver, adenosine doesn’t even make it that far, being metabolized in the erythrocytes and vascular endothelial cells. With this extremely short half-life (10 seconds), it is important to help it reach the heart before it’s metabolized and excreted without being effective.
You need to perform an ultrasound on your patient. You walk up to the ultrasound and upon grabbing the machine, you notice it’s stuck! You look down and realize the ultrasound probe cable (particularly the linear probe) is impeding the wheel from rolling. You push the machine back, pick the cable up off the floor and off you go to scan to find that the probe is not working. As you try to figure out why it’s not working, you realize that the cable is exposed after repeated damage from the countless times the wheels on the machine rolled over the cable. Let’s prevent this from happening!(more…)
A 25-year-old medical student comes in with a muffled voice, sore throat and trismus. You look at the back of her throat and you see the uvula deviated to the right. You astutely diagnosed a peritonsillar abscess (PTA). You consider aspirating and want to check for tips on how to successfully do this.
Dr. Michelle Lin and Dr. Demian Szyld have created great guides for the common and important emergency medicine procedure of draining a PTA (laryngoscope lighting and spinal needle for aspiration; ultrasound localization and spinal needle guard; avoiding awkward one-handed needle aspiration). This update reviews these tricks as well as some additional techniques for optimal success in draining a PTA, while avoiding the ultimate feared complication of puncturing the carotid artery.
Severe constipation, requiring fecal disimpaction and rectal enemas, can be excruciatingly painful for patients. Administering sedatives and opioids to help alleviate this pain poses a challenge, because many of the patients are elderly and tend to be more sensitive to these medications. Furthermore, there may be increased vagal tone when straining, leading to hypotension and bradycardia and which can result in defecation-related syncope. 1 Also, opioids can exacerbate constipation. Herein we present 2 cases and tricks on achieving better pain control.
The safe placement a central venous catheter (CVC) remains an important part of caring for critically ill patients.1 Over 5 million CVCs are placed each year in the United States. It is crucial to confirm that the central line is placed in the correct position in order to rule out potential complications of the procedure (e.g. pneumothorax) and begin administration of life-saving medications. Post-procedure chest radiographs (CXR) are the standard of care for CVC placements above the diaphragm. However, the annual cost to the U.S. healthcare system for CXRs after CVC placement is estimated to be over $500 million.2 Further, in a busy ED, the limited availability of portable radiography may pose a considerable time delay. Radiography may also be limited in resource‐poor and austere settings, particularly the prehospital and military environments. We review a faster, cheaper, and more accurate alternative for evaluating CVC placement: point of care ultrasound (POCUS).(more…)
A hair tourniquet occurs when a strand of hair coils around a patient’s appendage. It can cause damage to the skin, nerves, or affect blood supply. It is more common in infants as their skin appendages are small which allows for hair or thread to trap inside. Because in some cases these pediatric patients can present with inconsolable crying, it is important to perform a thorough physical examination to evaluate for the presence of such a hair tourniquet. We present a simple trick for removing a hair tourniquet using depilatory cream!