Trick of the Trade: Difficult intubation -- making lemonade out of lemons

(Image from http://xela145.deviantart.com)

In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn't adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.

Trick of the Trade:
Leave the esophageal tube in.
Reattempt endotracheal intubation.

"When life gives you lemons, make lemonade."

If the endotracheal tube is in the esophagus, do NOT take it out! You have just created a conduit to remove further bleeding from the field. Take another look with Yankauer suction. Reattempt your intubation with a second tube. Do this as soon as you recognize an esophageal intubation to reduce the patient's risk for oxygen desaturation.

Note:

1. Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
2. Have an assistant suction the proximal port of the esophageal tube when blood starts pouring out of it.

Thanks to Dr. Marianne Haughey and Dr. Peter Gruber (Jacobi Medical Center) for sharing this tip. Quick thinking!

Paucis Verbis: Pediatric fever without a source (Birth-28 days)

Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient's age. Today's PV card focuses on the youngest age group: Birth-to-28 days.

QUESTION to everyone:

• Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I've seen varying practices.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Trick of the Trade: Minimizing propofol injection pain

"Ow, that burnnnnssss... ow! ow! ow! ... zzzzzz..."

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it's too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds.

What can you do preemptively to minimize the pain of propofol injection?

Tricks of the Trade:

1. Place the IV in an antecubital vein (vs the hand).
2. Pretreat with IV opioids.
3. If the IV is in the hand, place a tourniquet proximally and pretreat with lidocaine.

The most effective thing you can do to minimize pain from propofol injection is to cannulate a vein in the antecubital fossa rather than in the hand. The relative risk reduction is 0.14. The larger, higher flow vein presumably reduces the pain. You should also pretreat the patient's pain with an IV opioid, such as fentanyl or morphine.

For the IV is in the hand, you should pre-treat with lidocaine. First, apply a tourniquet. Intravenously inject 0.5 mg/kg of lidocaine. For a 70 kg person, that's 35 mg. This equals 3.5 mL of 1% lidocaine. Release the tourniquet after 30-120 seconds, and inject the propofol. The number-needed-to-treat to prevent pain in one person, who would have had pain had they received placebo, is 1.6!

Thanks to Dr. Andy Neill (of Emergency Medicine Ireland blog fame) for the tip from the Life in the Fast Lane's Research and Reviews series.

Reference
Jalota L, et al. Perioperative Clinical Research Core. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15;342:d1110. PMID: 21406529.
Free PDF

Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg. 2000 Apr;90(4):963-9. PMID: 10735808.

Paucis Verbis: Antibiotics and open fractures

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.

Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?

Pearl: Once you have significant soft tissue injury, you are automatically have a Type III open fracture and should add an aminoglycoside.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference:

Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic  antibiotic use in open fractures. J Trauma. 2011 Mar;70(3):751-4. .

Is this right IJ central line correctly placed as noted on chest x-ray?

Blue dot marks tip of IJ.   Contrast adjusted to maximize clarity of IJ and tracheobronchial angle.  Click on image to enlarge.

IJ should be pulled back 1-2 cm.  Ideal location is at the superior vena cava/atrial junction which is located  3-5 cm below the tracheobronchial angle, a distance which is reproducible in patients despite gender and body habitus. 


Source

Emedhome.com.  Clinical Pearls: "Proper Position of a Central Line."  7 April 2010.

Marcucci, L. Avoiding Common ICU Errors.  "Place the Tip of a Central Venous Catheter at the Junction of the Superior Vena Cava and Atrium"  Lippincott Williams & Wilkins.  2007.

Heuristics and Cognitive Biases in Decision Making During Clinical Emergencies

When faced with a potential clinical emergency situation, physicians are often expected to make diagnostic decisions within a limited time frame. A delayed decision, albeit an accurate one, is a futile decision if the patient deteriorates. Therefore, as almost always, such urgent decisions have to be made with some degree of uncertainty. This is especially so in an environment like the emergency

Trick of the Trade: Dental Avulsion/Subluxation

It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground.  She’s crying because of the event but is otherwise unscathed.  At this point it’s time to take care of the avulsion.  What to do? (see PV Card on ED Treatment of Dental Trauma)

Trick of the Trade:

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

1. Lightly rinse tooth with saline solution.
2. Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
3. Gently reimplant tooth into a satisfactory anatomic position.
4. Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, "mesial" means right edge and "distal" means left edge in dental speak.
5. Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
6. Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
7. Hold the splint under pressure for about 1 minute.
8. Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings:

• Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
• Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.

Reference

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

29 y/o male has left sided chest pain which started after falling off a ladder. Identify the pathology on the chest and rib x-rays.

What pathology are the red arrows pointing at? Orange? Green?

PA chest x-ray.  Click on image to enlarge.

Left rib x-ray

Oblique left rib x-ray.

Red arrows denote the two rib fractures.  Orange arrows, subcutaneous air.  Green arrow, small apical pneumothorax.

The rib fractures and subcutaneous air are pretty easy to identify.  Finding the pneumothorax is a little more difficult but here are a couple tricks to picking it up.

1. Blunt (not penetrating) trauma + rib fracture + subcutaneous air = pneumothorax.  Find it.  
2. First place to look for a pneumothorax on an upright chest x-ray is in the upper hemithorax as air in the pleural space will rise.   Most common appearance is an area adjacent to the ribs where no lung vascularity is seen and where a very thin white line represents the visceral pleura.

Source

Mettler: Essentials of Radiology, 2nd ed.

Paucis Verbis card: Interpretation of intraosseous blood

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Here's another one!

Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Michael McGonigal at Trauma Professional's Blog for posting about this.

Reference
Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010 Sep;134(9):1253-60. Pubmed
.

Students/residents: Free 1-yr subscription to PEMSoft

A January 2012 special! 

It is still the season of giving… for medical students and residents. 

The Editors-in-Chief of PEMSoft (Pediatric Emergency Medicine Software) want to share a one-year free subscription to a dynamic online pediatric EM reference. PEMSoft brings the medical library to the bedside! It is a point-of-care clinical support tool and knowledge system that is indispensable if you care for sick neonates or young adults. PEMSoft is also a superb educational resource--with over 3000 images and videos, as well as multiple interactive modules to refine diagnosis and treatment, and a sophisticated search engine to find topics instantly and to generate differential diagnosis.

PEMSoft has had a total makeover in 2012, with more than 8 special modules added to the updated vast, core knowledge base that now includes over 2000 topics. This new interface is especially suited for use on tablets and mobile devices at the bedside and on rounds. Previous reviews of the software have declared it "a new publication that completely resets the standards in its field" (Ped Emerg Care, 23(8); 2007). Test it out the new version for yourself! See our informational website at www.pemsoft.com for more details and testimonials from your colleagues.

I recently delivered donated versions of PEMSoft and trained tons of grateful physicians in Vietnam, on behalf of KidsCareEverywhere. A personal subscription of the online software currently currently costs $95/yr. In full disclosure, I am one of their section editors. I manage the multimedia Procedures section. If you listen closely, you'll hear my voiceover in several of the videos.

• Visit our informational website: www.pemsoft.com
• Enter the software itself: www.pemsoft.net
• "Like" us on Facebook: http://alturl.com/kwpsz

How do you get this amazing 1-year free subscription? Fill out the form below, and I'll personally email you your username and password.

The deal expires Jan 31, 2012.

Trick of the Trade: A removable guidewire

An essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used elsewhere. For instance, what's your go-to approach when looking for a spare guidewire? Let's say you are trying to salvage an ultrasound-guided basilic vein IV catheterization.

Here's where I go for guidewires:

• Central line kits
• Pneumothorax pigtail kits
• Seldinger-based cricothyrotomy kits

Trick of the Trade:
Seldinger-based Arrow arterial lines

Thanks to Dr. Kennedy Hall (UCSF-SFGH EM resident), he recently discovered that the Seldinger-based arterial lines, made by Arrow, have removable guidewires! If you look closely along the length of the transparent guidewire sheath, there is a narrow slit which allows you to remove the guidewire. The added bonus is that there is a black plastic handle at one end of the guidewire which can protect against losing the guidewire into a catheter.

Whoa, it's like magic.

Neither Dr. Hall or I have any financial disclosures with the Arrow company.

Blog Incubator Experiment: Be the next big thing in blogging

There are many health and technology incubators out there, which help to build start-up companies into thriving and profitable organizations.

Why can't we do this for those who are thinking about starting a blog? In 2009 when I was thinking about starting the blog, I had lots of support and encouragement. I slowly grew my readership by word-of-mouth and things really got going when the folks over at Life in the Fast Lane, Poison Review, EMCrit, and so many more graciously pointed their readers toward my site.

So for those of you interested in joining the Web 2.0 world and shifting your role as a "consumer" to "producer", I wanted to open up a competition: The Blog Incubator Experiment. I am soliciting applications for a person or team to write a 3-part series on Academic Life in Emergency Medicine.

• You get an automatic readership with at least 300 hits per day. 
• You get a taste of whether you want to start up your own blog. 
• You see in the inner workings of a blog.

Eligibility: 

• You can not currently have a blog in the area that you are writing about.
• You can be a medical student, resident, attending physician, physician assistant, nurse practitioner, nurse, or prehospital personnel in any specialty.

How to apply:

• Email me (Michelle.Lin@emergency.ucsf.edu) your thoughts and vision for the 3-part series. Be as detailed as possible, and be creative!
• You can submit more than 1 idea for the series.
• The topic(s) for the series should be relevant to those practicing Emergency Medicine, and/or interested in education.
• If selected, I would like to receive your 3 blog posts by March 1, 2012. 

Deadline: January 31, 2012 at 5 pm (EST).

Notification of winner: February 7, 2012

Paucis Verbis: Serotonin syndrome

What exactly IS serotonin syndrome? 

It's caused by the excess of serotonin and presents classically as:

• Altered mental status
• Autonomic instability
• Neuromuscular hyperactivity

Fortunately, there's a nice algorithm (Hunter's decision rule) which helps you decide whether it is serotonin syndrome or not. I also include a table, which I adapted from the New England Journal of Medicine review article on Serotonin Syndrome, which helps you to differentiate it from its mimickers, such as anticholinergic syndrome, neuroleptic malignant syndrome, and malignant hyperthermia.

(click to zoom in)

A video to remind you what clonus looks like:

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Steve MacDade (Univ of Florida, Jacksonville EM resident) for the idea!

Reference

Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Fam Physician. 2010 May 1;81(9):1139-42. Free AFP text.


Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. .

Trick of the Trade: Hip dislocation Part II

As a followup to the blog on the Captain Morgan technique for hip dislocations, I'd like to throw out another similar technique that also does NOT involve climbing up on the gurney.

The Whistler technique was developed in the ski town of Whistler, B.C., where the majority of their hip dislocations resulted from either a skiing or snowboarding accident. The technique applies the same principles as the Captain Morgan technique but uses the provider's forearm instead of their knee in the popliteal fossa.

1. The patient lies supine on the gurney.
2. Unaffected leg is flexed with an assistant stabilizing the leg. The assistant can also help stabilize the pelvis.
3. Provider's forearm is placed under the affected leg in the popliteal fossa then grasps the knee of the unaffected leg.
4. Provider's other hand grasps the lower leg of the affected leg, usually around the ankle.
5. The dislocated hip should be flexed to 90 degrees.
6. The provider's forearm is the fulcrum and the affected lower leg is the lever.
7. When pulling down on the lower leg, it flexes the knee thus pulling traction along the femur.
8. You can also add some internal/external rotation to facilitate the reduction.

Is it the definitive hip dislocation reduction technique? No...but something else to add to your bag of tricks when the usual doesn't work.

I've used the Whistler technique multiple times with success. The few times it hasn't worked, I've converted to the Captain Morgan technique. No more gymnastics on the gurney!!!

Has anyone else tried it?

Reference
Walden PD, Hamer JR. Whistler technique used to reduce traumatic hip dislocation of the hip in the emergency department setting. J Emerg Med.1999 May-June;17(3):441-4. Pubmed