A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.
You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don’t hear a rush of air. The patient’s clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?
Is this coin in the esophagus or the trachea?
The classic teaching for the Boards exam is:
Have you ever accidentally flicked a drop of blood while disposing a straight guidewire into a rectangular sharps bin? The bins just don’t quite fit the wire easily. That’s just an occupational exposure just waiting to happen to yourself.
The electrocardiogram can pick up all sorts of electrolyte abnormalities. The most common abnormalities revolve around high and low levels of potassium and calcium. Magnesium derangements typically have nonspecific findings. How do you keep things straight? To make things more complicated, multiple electrolyte derangements can occur at the same time, making ECG interpretation challenging.
Having you had trouble seeing a pediatric patient’s tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid curette and caused bleeding in the ear canal? The parents are worried that you hit the brain…
In U.S. academic emergency departments, decisions to accept patients is typically easy, because you have ready access to on-call physicians. When in doubt, accept transfer patients and sort things out later.
As a general rule, the liability falls upon the transferring site and physician. So be sure that your patient won’t decompensate in the ambulance during transfer. So, don’t transfer that CP patient who is getting ruled-out for an MI or ACS no matter how good they look. Patients need to be stable for transfer.
Anyone with pearls to share?
Thanks to @EMurgentologist for tweeting me the idea!
Go to ALiEM (PV) Cards for more resources.
Further Reading:
A 41 y/o m presents to your ED after an occupational exposure to 30% hydrofluoric acid (HF). The thumb and index finger of his right hand were affected. Upon visual examination, the site of exposure looks relatively benign but the patient is complaining of extreme pain. Beyond giving opioids, what can you do?