tPA Administration: Don’t Forget the Leftover Volume in the Pump Tubing
Whether alteplase (tPA) is given for ischemic stroke, pulmonary embolism, or STEMI, there is an important practical issue to be aware of during administration. Dr. Charles Bruen (@resusreview) published a great step-by-step pictorial tPA Mixing Tutorial. Once the tPA is mixed, it will invariably be infused via a smart pump through its corresponding tubing. At my institution we use Alaris® CareFusion smart pumps, through the principle applies irrespective of which brand pump is used. [+]
ALiEM Hiatus
We are undergoing some server upgrades before our two fellowships begin on July 1. Let's all cross our fingers and toes that we can move the 1,000+ posts and database safely over to a faster and more reliable server! Will hopefully be back in a week.
PV Card: Local anesthetic toxicity calculations
Local anesthetics (LAs) are widely employed to achieve tissue infiltration, peripheral and regional anesthesia, and neuraxial blockades. Despite their well-established toxic dose limits, these agents continue to pose a substantial risk of morbidity and mortality due to local anesthetic toxicity and overdose. For example, LAs and epinephrine account for a large proportion of medication errors resulting in adverse patient outcomes due to drug dosing miscalculations or errors converting between units. Dosage calculations vary by patient weight as well as by pharmacokinetics and pharmacodynamics of individual LA formulations. Further, non-standard units, additives (epinephrine), and varying concentrations among LAs complicate correct dosage [+]
AC Joint Separations: Overview of diagnosis and treatment
Separation of the acromioclavicular (AC) joint is a common injury encountered in the emergency department. Keys to optimal outcome and return of function in these patients include knowledge of injury mechanism, diagnosis and classification, and initial treatment. [+]
High risk back pain: Cauda Equina Syndrome (EREM)
Cauda equina syndrome (CES), which occurs due to compression of the distal lumbar and sacral nerve roots, is a potentially devastating cause of back pain. CES is often missed on the patient’s initial visit which can lead to significant neurologic compromise in a matter of hours [1]. To improve patient outcomes and minimize medicolegal risk, providers need to understand the limitations of the history and physical and carefully consider the diagnosis of CES in any patient with back pain. [+]
MEdIC Series: The Case of the Exasperated Educator – Expert Review and Curated Commentary
The Case of the Exasperated Educator presented an attending at the end of a difficult shift with a learner that just didn’t seem to “get it.” As the new attending coming on shift, how can we help our colleague and his student? How can we avoid getting ourselves into a similar situation? No matter patient we are, odds are that we will all find ourselves in these roles at some point or another. Check out the ALiEM community’s discussion of the case. [+]
Research Figures Demystified: Bland-Altman Plot
While working your shift in a small community ED, you overhear that EMS is on their way to you with a five-year-old child in respiratory distress after eating a peanut butter sandwich. Anticipating the patient to be in anaphylactic shock, you and the senior resident begin planning the course of action. The resident asks, “how much do you think a five-year-old weighs?” While you begin fumbling for your Broselow tape, a nurse seated near you confidently responds, “That’s easy, just count your fingers! One, three, five. Ten, fifteen, twenty! The child weighs approximately twenty kilograms!”. [+]
Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers?
Rate control with IV medications is recommended for atrial fibrillation in the acute setting in patients without preexcitation. This was a Class 1 recommendation (Level of Evidence B) per the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation [1]. What does the evidence say? Are calcium channel blockers or beta blockers better? [+]
Simulation Trick of the Trade: Bleeding Cricothyroidotomy Model
One advantage of simulation as an educational tool is the re-creation of cognitive and emotional stresses in caring for patients. Doing this for a high fidelity scenario is relatively easy – add additional patients, make a them loud, combative, or otherwise cantankerous, and add interruptions for good measure. However, when training for procedures in the simulation lab, we practice the procedure in isolation on a “task trainer” without cognitive and emotional stress for context. An off-the-shelf task trainer can do a superb job of teaching the mechanics of performing a procedure, but they lack complexity necessary to train for performing the procedure under stress. [+]
Transitions of Care: Top 10 things admitting providers wish we did for older adults
“Transitions of care” has become a hot topic in the care of older adults. It is usually applied to the transition from the hospital to home or the hospital to a nursing facility. But what about the transition from the ED to an inpatient service? It turns out there are plenty of things we could be doing (or not doing) to help smooth that transition and improve patient care. Here are some thoughts from admitting physicians with geriatrics training. [+]