Putting an Older Patient Under: Tips for Geriatric Procedural Sedation
An 84-year old woman presents to your ED with a traumatic, left-sided posterior hip dislocation. You need to reduce the hip. But how should you sedate her? Procedural sedation is an important component of ED care. It allows us to more comfortably perform otherwise painful procedures such as fracture or dislocation reductions, endoscopies, large laceration repairs, and I&Ds. How safe is procedural sedation in older adults? […]
Introducing REBEL in EM and IM
As a physician and newcomer to FOAM, I am finding that I have learned a lot of myths and pearls that are not true as I matriculated through school. This has taught me that learning from textbooks may be great for board exams, but more importantly it is not optimal for patient care and has made me question a lot of different practices. We all want to know clinically relevant information that is evidence based and up to date that will make a difference in our care of patients. The purpose and goal of REBEL is to create a sustained change [...]
Epinephrine Dosing for Anaphylaxis in Patients on Beta-Blockers
I love when complex medication questions come across my desk from folks like Drs. Amal Mattu, Rob Orman, Mike Winters, and Haney Mallemat (just to name a few). This week I received one from Dr. Scott Weingart that someone had sent to him. This paramedic was reviewing his anaphylaxis protocol with some new medics and providers. They asked a challenging question regarding a “pearl” they learned in which half-dose epinephrine should be administered in anaphylactic patients on beta-blockers. Patients on beta-blockers do have an increased risk for anaphylaxis, so there is a chance you’ll see a case just like this at [...]
CPR: Hands-on or Hands-off Defibrillation?
Pauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology including: Biphasic shocks with real-time impedance monitoring to reduce peak voltages Paddles being replaced by adhesive pre-gelled electrodes Enhancement in ECG filtering permitting rhythm monitoring during chest compressions. So the mantra of “hard and fast” may be true when it comes to CPR, but the [...]
Patwari Academy Videos: Evidence Based Medicine (part 5)
In this fifth and final installment of the Evidence Based Medicine series, Dr. Rahul Patwari reviews the concepts of: distribution of the means (with case examples), confidence intervals, accuracy, precision, and the student t-test (with an example). […]
Mechanical vs Manual CPR Chest Compressions
When talking about Out of Hospital Cardiac Arrest (OHCA) there are really only three things that make a true difference on outcomes (i.e. survival and neurologic function): High quality, non-interrupted CPR Early defibrillation Therapeutic hypothermia The quality of CPR is often under appreciated and performed incorrectly (too slow and/or not hard enough). With mechanical CPR, chest compressions are delivered uninterrupted and at a predefined depth and rate. In my own practice I have seen these devices being used more and more, but my questions is do these devices impact outcomes? […]
P-Video: Rule of 15 in anion gap metabolic acidosis
You have a patient with an anion gap of 30 and bicarbonate of 10 mEq/L. You also determine on VBG that the patient’s pCO2 is 25 mmHg. What trick of the trade can you use to quickly determine whether this low pCO2 is an appropriate compensation of the primary metabolic acidosis? Dr. Jeremy Faust and Dr. Corey Slovis explains the quick “Rule of 15”. […]
Patwari Academy Videos: Evidence Based Medicine (part 4)
Dr. Rahul Patwari is a one-man statistics teaching machine. In part 4 of this Evidence Based Medicine series, he reviews advance concepts in statistics and calculations including: case-fatality rates, crude mortality rates, specific-mortality rates, years of potential life lost, and direct and indirect age adjustments. […]
P-Video: Sources for pediatric and adult fevers
Dr. Jeremy Faust is back with another P-video, which stands for Paucis Videos (paucis means “few” or “brief” in Latin) much like the Paucis Verbis cards. These P-videos are short video-based educational pearls for the practicing physician with a focus on Emergency Medicine and Critical Care. Here Jeremy shares two mnemonics, LUCAS and FEBRILE, to help you remember the common causes for fevers in pediatric and adult patients, respectively. […]
Confessions of an Emergency Department Kid Helper
As I was rounding the corner from the adult area of the emergency department to the pediatric area I heard a child screaming at the top of his lungs, “I DON’T WANT A SHOT”. I knew at that moment I was being summoned. I walked into the room and I saw a mother with her 5 year old son in a full headlock, while a new intern was trying to look in his ears. I made eye contact with the intern said “maybe I can help” then turned my attention to mom and son. […]