An urethral Foley catheter can sometimes become retained in the bladder, because of its balloon being unable to deflate. A malfunctioning inflation valve or obstructed channel along the length of the catheter is the cause.
How can you deflate the balloon so that the Foley catheter can be removed?
In the Emergency Department, we often order urine toxicology screens for patients with altered mental status without an obvious cause. I find that patients are often rather forthcoming about their drug use, if they are alert enough to talk. In those cases, ordering a urine toxicology screen is unnecessary.
When you do order a tox screen, however, how do you interpret the information? While the result is a binary answer (positive vs negative), there are some nuances to interpretation. For instance, how long does a patient with urine toxicology remain positive for the drugs? Are there any medications that can cause false positives? See the helpful table below from a great review article in American Family Physician.
Check out what your laboratory screens for and, more importantly, what it does NOT screen for. Our lab, for example, does not screen for PCP but does screen for MDMA (ecstacy). That isn’t a big deal, since patients who ingest PCP aren’t too hard to detect clinically. They have crazy vertical nystagmus, and often there are at least 6 police officers trying to restrain the yelling patient.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Patients often present to the Emergency Department for mandibular blunt trauma. Usually these patients have soft tissue swelling at the point of impact. In mandibular body fractures, the fracture line often extends to the alevolar ridge. This may cause a gap between a pair of lower teeth.
In patients with jaw pain, mild swelling, and normal dentition, is there a way to avoid imaging these patients to rule-out a mandible fracture?
The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications.
Go to ALiEM (PV) Cards for more resources.
Occasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren’t sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)?
What test can you do to reassure yourself that this may indeed be psychogenic coma?
When I did my residency training in Emergency Medicine and in the first few years as an attending, we regularly performed diagnostic peritoneal lavages in patients with stab wounds injuries to the abdomen. Patients also routinely went to the operating room for exploration.
Now with the evolution of CT imaging technology and more clinical studies, there is now a role for a less invasive management approach. These are the Eastern Association for the Surgery of Trauma (EAST) guidelines.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Burn classification and management are key skills for ED providers to remember. Depending on the prevalence of burns in your ED, it may be hard for forget the details. So here is a PV reference card on the rule of 9’s, different classifications of burns, and indications for burn unit referral.
Update (April 22, 2016): This card was updated by Dr. Christian Rose (UCSF-SFGH) to reflect current evidence that topical antibiotics and honey are IN, while silver sulfadiazine is OUT for partial-thickness burns.
Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.