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…)
Welcome to the Non-ACS Cardiovascular Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the AIR Team is proud to present the highest quality online content related to non-acs cardiovascular emergencies. 5 blog posts within the past 12 months (as of September 2018) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 3 Honorable Mentions. We recommend programs give 2.5 hours (about 30 minutes per article) of III credit for this module.(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
After receiving numerous high-quality submissions, we are proud to announce the winners of the 2019 Essentials of Emergency Medicine (EEM) Education Fellowship contest! Dr. Tim Montrief from the Jackson Memorial/University of Miami Emergency Medicine residency program has won the blog post competition. A blinded EEM voting panel with input from ALiEM selected his winning post: Trick of the Trade: Bubble Study for Confirmation of Central Line Placement. We are thrilled to feature it today on the blog and look forward to meeting him in Las Vegas in May at the 3-day event. This weekend, we will also feature 2 other excellent submissions from runners-up Dr. Sarah Sanders (Northwestern University) and Dr. Jennifer Rabjohns (George Washington University). Thank you to everyone who submitted their work!
Dr. Tim Montrief
Emergency Medicine Resident
Jackson Memorial/University of Miami
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…)
Symptomatic influenza A and B infections cause worldwide morbidity and mortality every year. Annual vaccination remains the greatest prophylactic measure, but the vaccine is not 100% effective due to mismatch between the circulating and vaccine virus strains. Although most individuals will recover from influenza without incident, some specific patient populations are at high risk for severe complications. The Infectious Disease Society of America (IDSA) recently updated their clinical practice guidelines.1 We review these key updates, including recommendations on who to test, treat, and provide chemoprophylaxis.