A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension pneumothorax.
You insert a standard 14g angiocather in the left 2nd intercostal space (ICS). You don’t hear a rush of air. The patient’s clinical condition deteriorates to impending asystole. How sure are you that your angiocatheter actually reached the pleural space?
Have you ever accidentally flicked a drop of blood while disposing a straight guidewire into a rectangular sharps bin? The bins just don’t quite fit the wire easily. That’s just an occupational exposure just waiting to happen to yourself.
Having you had trouble seeing a pediatric patient’s tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid curette and caused bleeding in the ear canal? The parents are worried that you hit the brain…
A 40-year-old man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air, and he has diffuse, tight wheezes on exam. You prepare to intubate the patient using a rapid sequence induction protocol: etomidate, succinylcholine, 8-0 endotracheal tube.
Or do you?
This pocket card discusses the delayed sequence intubation (DSI) protocol made famous by Dr. Scott Weingart and Dr. Rich Levitan.1 Thanks to Dr. Michelle Reina (EM resident at Univ of Utah) and Dr. Rob (Intermountain Medical Center in Utah) for designing this helpful card. Rob has even implemented a DSI protocol in his ED.
The card breaks down the reasoning and steps behind DSI. Anecdotally, ketamine has often calmed patients down enough during the preoxygenation phase to enhance oxygenation/ventilation so much so that intubation is not required.
Go to ALiEM (PV) Cards for more resources.
Bartholin abscesses are challenging to manage, partly because of Word catheter insertion. Sometimes, the space is not large enough (unable to fit the catheter) or too large (catheter falls out). How else can you “pack” the abscess space?
Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.
Incision and loop drainage (I&LD) technique
As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.
It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.
Does anyone have experience with this that they would like to share? Particularly, what if you don’t have the skinny vascular loops in your Emergency Department?
Per the Tsoraides article1: