A 63-year-old male presents for acute onset of headache, neck pain, and altered mental status. He has a prior history of hypertension and hyperlipidemia but recently lost his insurance and has been unable to fill his medications. As a well-informed 2nd year resident, you suspect the presence of a ruptured subarachnoid hemorrhage and arrange an expedited trip to the CT scanner. The patient’s blood pressure continues to remain elevated and you initiate an antihypertensive drip. You decide that in order to have accurate titration, you need more reliable data and decide to place a radial arterial line. However, the last two arterial lines you placed did not go according to plan! Before you start the procedure, you decide to review the procedure and some common pitfalls in placing radial arterial lines. You remember your attendings telling you during prior attempts to do things a certain way and you want to incorporate these in your practice.
End-tidal CO2 (EtCO2) monitoring is a measure of metabolism, perfusion, and ventilation. In the ED, we typically think of a EtCO2 as a marker of perfusion and ventilation. However, EtCO2 is an extremely powerful surrogate for endotracheal tube (ETT) Position, CPR Quality, Return of spontaneous circulation (ROSC), Strategies for treatment, and Termination (of CPR). Do these letters look familiar? They should! In this post we take a deep dive into each of these potential uses of EtCO2 in the ED.(more…)
A 28-year-old G4P3 at 41 weeks presents to the ED via EMS. She is in active labor. On exam, a neonatal head is visible. Two minutes later, you deliver a healthy vigorous baby boy and hand him to your colleague. You notice persistent bleeding from her vaginal canal. Her tachycardia climbs to 110 bpm and her latest blood pressure is 78/48 mm Hg. We review postpartum hemorrhage (PPH) and the 4 T’s – a memory aid to help ED providers manage this life-threatening presentation.(more…)
Cricothyroidotomy is an emergency life-saving procedure that involves surgical placement of a tube through the cricothyroid membrane in order to establish a patent airway for oxygenation and ventilation. The indications for this procedure are when traditional means, such as orotracheal or nasotracheal intubation, are contraindicated or have failed during attempts to establish an emergency airway.1,2 It is a critical skill for emergency physicians but the declining rate of this procedure has resulted in decreased exposure during training.3,4
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…)
Accidental hypothermia is a life threatening condition that can lead to a challenging resuscitation. The very young, old, and intoxicated patient are at high risk to developing hypothermia, even in temperate climates. The pathophysiologic changes from hypothermia make the standard ACLS approach insufficient to care for the hypothermic patient. This article will discuss the physiology of hypothermia and how you should alter your approach in the hypothermic patient, including early consideration of extracorporeal membrane oxygenation (ECMO).
Drowning cases peak this time of year and represent a leading cause of mortality in children. For example, drowning represents the leading cause of death in boys ages 5-14 years old, and worldwide, there are 500,000 annual deaths from drowning.1 Hypoxic injury and subsequent respiratory failure represent the primary causes of morbidity and mortality. Although providers are typically taught to be aware of possible trauma (e.g. cervical spine fracture) when evaluating a drowning case, less than 0.5% of drownings are traumatic.2 The duration of immersion, volume of aspirated fluid, and water temperature dictate clinical outcomes.1 We review the presentation, pathophysiology, and management of drowning to raise awareness about this important public health issue.