Academic Life in Emergency Medicine

Video: Crash course on Prezi

noreply@blogger.com (Michelle Lin, MD) — Mon, 27 Feb 2012 11:00:00 +0000

Dr. Rob Rogers has started a great series of videos which highlight resources and tools which medical educators may find useful and innovative. This video takes you on a guided tour through making a Prezi presentation. Although I am still torn about using Prezi as a delivery tool because of the excessive motion-based transitions, I do like such features as:

Really professional looking templates
The presentations can live online and/or on your desktop
Ability to easily embed videos
Ability to see your entire presentation on the canvas
Allows more flexibility in content delivery
It just looks cool.

You can look for more excellent videos on the Academic Emergency Medicine Education Masters site. Hey maybe you can next teach people how to use Google Reader, Evernote, Dropbox!

Paucis Verbis: Anaphylaxis

noreply@blogger.com (Michelle Lin, MD) — Fri, 24 Feb 2012 11:00:00 +0000

Image from WebMD

Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical.

A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of "rebound" or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn't a good answer for this.

What's your practice in dispositioning these patients? Personally, I admit at least those patients who present with severe hypotension, require more than 1 epinephrine dose, or have poor social support.

NOTE: Unlike the photo on the top, warn patients not to rest their thumb on the device because of the risk inadvertent needle puncture.

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

See other Paucis Verbis cards.

Reference

Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S161-81. .

Arnold JJ, Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011 Nov 15;84(10):1111-8. .

On vacation

noreply@blogger.com (Michelle Lin, MD) — Fri, 17 Feb 2012 11:00:00 +0000

Had an exciting week making new friends and learning about hot topics in Emergency Medicine at our department's UCSF High Risk Emergency Medicine Hawaii conference.

Will be back next Friday!

Live-blogging: UCSF High Risk EM Hawaii conference

noreply@blogger.com (Michelle Lin, MD) — Wed, 15 Feb 2012 16:00:00 +0000

Today is the pre-day for our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. Keep a lookout below as I try to live-blog some of the clinical pearls that I glean from the day (using Google Docs).

Live blogging tomorrow

noreply@blogger.com (Michelle Lin, MD) — Tue, 14 Feb 2012 11:00:00 +0000

Tomorrow is the beginning of our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. I'm going to try to live-blog some of the clinical pearls that I glean from the day.

Article review: New assessment method for medical students - A Script Concordance Test

noreply@blogger.com (Stella Yiu) — Mon, 13 Feb 2012 11:00:00 +0000

What different ways can we assess learners?

This fascinating study assesses a new tool - Script Concordance Test (SCT).

Assessing clinical reasoning skills in scenarios of uncertainty: Convergent validity for a Script Concordance Test in an Emergency Medicine clerkship and residency

What are Scripts?

Scripts are organized networks of knowledge. Integrating them improves decision making. Using scripts, experts see associations while novices struggle with causality. In ambiguous cases, experts process multiple scripts with influx of new information.

What is the format of a Script Concordance Test?

The learners are presented with a short clinical vignette with a series of proposed diagnoses and/or plans. The learners are then presented one new piece of information and asked what effect this information has on the proposed diagnoses and/or plans. They score their decisions on a Likert scale, ranging from -2 to +2.

What did this paper study?

An observational study comparing the scores of 4th year med students (n=314) , residents (n=40) and faculty (n=12) on a SCT with scenarios in Emergency Medicine. The student score was compared to USMLE Step 2 score, and resident score with their ABEM in-training exam score.

What were the results?

The SCT scores were able to differentiate students from residents and residents from faculty.

Students vs residents: 60% +/- 6.2 vs 70% +/- 5.4
Residents vs faculty: 70% +/- 5.4 vs 79% +/- 2.9

There was a significant correlation between resident score and ABEM exam score and a modest correlation between student score and USMLE Step 2 score.

What were the limitations?

It is a single centre study. The internal reliability of the assessment tool was suboptimal.

What were the conclusions?

The SCT may be useful in assessing clinical reasoning in uncertain scenarios.

What do I think?

I enjoy the examples given in the paper. While it is different and likely will take some getting used to, it could be a useful assessment tool.

References

Humbert AJ, Besinger B, Miech EJ. Assessing clinical reasoning skills in scenarios of uncertainty: convergent validity for a Script Concordance Test in an emergency medicine clerkship and residency. Acad Emerg Med. 2011;18(6):627-34. .

Paucis Verbis: Pediatric fever without a source (3 mo-3 yr)

noreply@blogger.com (Michelle Lin, MD) — Fri, 10 Feb 2012 11:00:00 +0000

In part 3 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants 3 months to 3 years old (PV cards for birth-28 days and 29 days-3 months old).

Notes:

The algorithm below is a guideline for NON-toxic patients. More ill-appearing children require a more broad workup.
For the under-immunized (<2 PCV immunizations) and temperature ≥39.5C, blood cultures may be falling out of favor in the near future, because the incidence of blood culture contaminants is close to exceeding the true incidence of occult bacteremia.

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

See other Paucis Verbis cards.

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.

Blog incubation project: New 2 winners!

noreply@blogger.com (Michelle Lin, MD) — Tue, 07 Feb 2012 11:00:00 +0000

And the winners of the first ever EM Blog Incubator competition are...

Dr. Jim Campagna (Emergency physician at St Joseph's Hospital Health Center in Syracuse, NY) and Dr. Timothy Peck (Beth Israel Deaconess EM resident in Boston, MA)

Both submitted really fascinating concepts for their blogs. I'm really looking forward to reading each of their 3-part introductory series in the upcoming weeks, as they prepare to launch their own blogs.

Dr. Jim Campagna

Jim plans to focus on the all-things-technology in Emergency Medicine. This includes reviewing and aggregating lists of medical apps and hardware which are relevant to the specialty. Furthermore, he will provide up-to-date literature reviews of other technologies, such as electronic medical records and computer physician order entry, and their impact on clinical practice.

Dr. Timothy Peck

Tim isn't a newcomer to the blogging world. He has a fantastic blog "Teach, MD: Rethinking medical education" since July 2011. On his new blog, Web 2.0 Changed My Management, will feature examples of how Web 2.0 influenced the management of specific patient encounters. Also guests will be allowed to contribute mini-case presentations where they will report how a Web 2.0 activity changed how they managed a patient.

I can't wait to see what Jim and Tim come up with!

Paucis Verbis: Fever without a source (29 days-3 months old)

noreply@blogger.com (Michelle Lin, MD) — Fri, 03 Feb 2012 11:00:00 +0000

In part 2 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that "high risk" infants get admitted with IV ceftriaxone and "low risk" infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the grey area.

Where I practice, we tend to follow a modified version of the Rochester criteria, where a lumbar puncture and antibiotics aren't always required for this age group (unlike the Boston criteria).

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 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: Difficult intubation -- making lemonade out of lemons

noreply@blogger.com (Michelle Lin, MD) — Tue, 31 Jan 2012 11:00:00 +0000

(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:

Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
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)

noreply@blogger.com (Michelle Lin, MD) — Fri, 27 Jan 2012 11:00:00 +0000

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

noreply@blogger.com (Michelle Lin, MD) — Tue, 24 Jan 2012 11:00:00 +0000

"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:

Place the IV in an antecubital vein (vs the hand).
Pretreat with IV opioids.
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

noreply@blogger.com (Michelle Lin, MD) — Fri, 20 Jan 2012 11:00:00 +0000

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. .

Trick of the Trade: Dental Avulsion/Subluxation

noreply@blogger.com (Hans Rosenberg) — Tue, 17 Jan 2012 11:00:00 +0000

It’s a Friday evening shift in the “minor area” of your EDand a young woman who had imbibed a little too much alcohol comes in with an avulsionof her first left upper incisor after falling and striking her face against theground. She’s crying because of theevent but is otherwise unscathed. Atthis 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 havealso 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.

Lightly rinse tooth with saline solution.
Rinse socket with 20-40 mL of saline solution and thenpat dry with a surgical sponge.
Gently reimplant tooth into a satisfactoryanatomic position.
Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to themesial 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.
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.
Secure the replanted tooth by applying 2-OCA to the inner aspect of thesplint and buccal surface of the target and one/both adjacent teeth.
Hold the splint under pressure for about 1 minute.
Confirm stability.

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

Warnings:

Children: Avulsedprimary teeth should not be replanted. Also ensure they will not be at aspirationrisk.
Warn the patient that if they feel that the dental splint is loosening, simplyremove 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.

Paucis Verbis card: Interpretation of intraosseous blood

noreply@blogger.com (Michelle Lin, MD) — Fri, 13 Jan 2012 11:00:00 +0000

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
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Students/residents: Free 1-yr subscription to PEMSoft

noreply@blogger.com (Michelle Lin, MD) — Wed, 11 Jan 2012 11:00:00 +0000

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.

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Trick of the Trade: A removable guidewire

noreply@blogger.com (Michelle Lin, MD) — Tue, 10 Jan 2012 11:00:00 +0000

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

noreply@blogger.com (Michelle Lin, MD) — Sat, 07 Jan 2012 23:39:00 +0000

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

noreply@blogger.com (Michelle Lin, MD) — Fri, 06 Jan 2012 11:00:00 +0000

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

noreply@blogger.com (Fred Wu) — Tue, 03 Jan 2012 11:00:00 +0000

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.

The patient lies supine on the gurney.
Unaffected leg is flexed with an assistant stabilizing the leg. The assistant can also help stabilize the pelvis.
Provider's forearm is placed under the affected leg in the popliteal fossa then grasps the knee of the unaffected leg.
Provider's other hand grasps the lower leg of the affected leg, usually around the ankle.
The dislocated hip should be flexed to 90 degrees.
The provider's forearm is the fulcrum and the affected lower leg is the lever.
When pulling down on the lower leg, it flexes the knee thus pulling traction along the femur.
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

Seasons greetings and happy new year!

noreply@blogger.com (Michelle Lin, MD) — Fri, 23 Dec 2011 11:00:00 +0000

We will be on a brief hiatus to count our blessings, reflect back on the year, and revel in good cheer. Happy holidays!

See you in 2012!

Trick of the Trade: Tie-over dressing for scalp lacerations

noreply@blogger.com (Michelle Lin, MD) — Tue, 20 Dec 2011 11:00:00 +0000

Scalp lacerations are apparently a hot topic these days. This is the third post now on how to apply a bandage to a scalp laceration.

Trick of the Trade:
Tie-over dressing technique

After suturing a laceration in place, leave the suture tails 6-8 cm long.
Roll up a piece of gauze.
Place the gauze roll on top of the sutured laceration.
Secure the gauze using the long tails of the sutures.
After 1-2 days, the patient should cut the tied-over knots to remove the gauze. This allows the wound to be inspected and cleaned.

For step-by-step photos, check out Dr. Gemma Morabito et al's Medicinadurgenza website post.

I have a question though:
I suture scalp lacerations only if the patient is balding or bald in the area. How would I bandage if you use staples instead of sutures for the scalp? I imagine my options:

Beanie hat approach
Hair braid dressing
Place 2-3 sutures to help close the laceration (interspersed amongst the staples) just to do a tie-over dressing
Don't bandage. Just cover up the staples with the overlying hair.

Thanks to Dr. Gemma Morabito (Rome, Italy) and Vincenzo Peloponneso (nurse in Cuneo, Italy) for the idea and images!

Reference
Ginzburg A, Mutalik S. Another method of tie-over dressing for surgical wounds of hair-bearing areas. Dermatol Surg. 1999 Nov; 25(11):893.

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Paucis Verbis: ACLS 2010 cardiac arrest flowchart

noreply@blogger.com (Michelle Lin, MD) — Fri, 16 Dec 2011 11:00:00 +0000

(click for larger images)

In a earlier summary of the 2010 ACLS guidelines, Dr. Demian Szyld succinctly highlighted changes from previous guidelines.

There are 2 flowcharts (above) that the AHA provides. They are conceptually complete, but I had a hard time implementing the steps in real-time.

So, I created my own. Thanks to Dan, who commented in my chat box that I should make an ACLS card.

Tips:

2 minutes of continuous, uninterrupted CPR is key before rechecking the rhythm.
Think about giving epinephrine every OTHER time you check the rhythm. This puts it at roughly a q4 minute dosing (recommended q3-5 minutes).
Don't delay CPR when you recognize a cardiac arrest. That means do this first, and then work on giving oxygen, placing the patient on various monitors, setting up the defibrillator, and establishing IV/IO access. Hence, the C-A-B mnemonic (Circulation before Airway)
Chest compressions should be "hard and fast" -- Depth of at least 2 inches and ≥ 100 compressions with a target pCO2 on the end-tidal capnography of ≥10 mm Hg.
Use your mobile phone's timer to help alert you every time when 2 minutes is up.

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

See other Paucis Verbis cards.

References

Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-67. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e236. Pubmed
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New kid on the block: ED Trauma Critical Care (EDTCC)

noreply@blogger.com (Michelle Lin, MD) — Wed, 14 Dec 2011 11:00:00 +0000

Welcome the newest EM blog to the block: ED Trauma Critical Care. It's helmed by Dr. Amit Maini (St. Vincent's Hospital in Melbourne, Australia) and focuses on keeping us all up to date with the latest and greatest in trauma, resuscitation, and critical care.

Topics thus far:

IO vs IV access during out of hospital cardiac arrest, an RCT
Increased chest compression fraction on ROSC in nonVF cardiac arrest
Beware the pain in the neck...
Sedation in traumatic brain injury
Slightly funnier than placebo
Severe pneumonia and ARDS

Keep a lookout for many more great summaries and tips.

Trick of the Trade: Captain Morgan technique for hip dislocation

noreply@blogger.com (Michelle Lin, MD) — Tue, 13 Dec 2011 11:00:00 +0000

Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient's bed.

Trick of the Trade:
Captain Morgan technique

You can apply 3 forces of axial traction to the femur.

Position the patient: 90 degrees of hip and knee flexion
Step one foot up onto the gurney Captain-Morgan style (flamboyant cape optional).
Position your knee behind the patient's knee.
Ideally your foot should be resting on a hard surface like a backboard to allow your foot to push off of it.
Place one hand (A) under the patient's knee and the other (B) over the patient's ankle.
Use Hand A to lift up on the patient's femur.
Plantar-flex your ankle so that your propped knee can lift up on the patient's femur.
Very gently use Hand B to leverage-down on against the patient's tibia/fibula.

TIPS FOR SUCCESS
Pearls straight from "Captain" Hendey (Dr. Greg Hendey wrote the article):

Make sure to put the patient on a backboard and attach a strap over the pelvis to stabilize it to the board--this works far better than having some tech trying to lie across the patient, and it's better than tying a sheet around the gurney and the patient. It also provides a firm place to put your foot.
Make sure to tuck your knee tightly under the patient's knee so that when you lift up on your tiptoes, all the force is transmitted into lifting the patient's hip. If your leg is much shorter than your patient's leg, you may need to put a book under your foot to get your knee tucked under theirs.
Once you're lifting, keep a steady sustained force, just like any large joint reduction--no sudden jerky movements. Once you feel it start to move, don't stop--sometimes people stop lifting too soon when they feel movement, but before the reduction has occurred.
If it's not moving, try rocking back and forth, and twisting the leg (internal and external rotation at the hip) while you're lifting.

Video 1:
The provider does not use Hand A to lift up, although it seemed that he kind of wanted to. Note that he was stepping on the hard bed under the soft gurney mattress.

Video 2:
The provider shows you how you really need Hand A to help you to lift.

NPR interview with the article's author and my friend, Dr. Greg Hendey (UCSF-Fresno).

Thanks to Dr. Graham Walker for letting us know about this great pearl from his new Gmergency! Tumbler site.

Reference
Hendey GW, Avila A. The captain morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011 Dec;58(6):536-40. Pubmed
.