Author Archive for: robbryant13

Post Intubation Hypotension: The AH SHITE mnemonic

20 Apr
April 20, 2017

You have just secured the endotracheal tube following an uneventful intubation of a moderately ill  patient in your emergency department. They had a normal pre-intubation blood pressure.  As you are calling the admit in to the ICU the patient’s nurse tells you that the BP is now in the 70’s.

NOW WHAT?

  1. Blindly give a half gallon of saline and stay in your seat.
  2. Get up, walk to the patient’s room, and consider the possible causes of post intubation hypotension.

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Altitude Adjusted PERC Oxygen Saturation

27 Mar
March 27, 2017

The PERC rule has been a welcome addition to the emergency department evaluation of patients with chest pain or dyspnea suspected of pulmonary embolism. This has allowed a reduction in D-dimer testing in low risk patients. The traditional saturation cut-off of 95% can pose a challenge for patients seen at higher elevations where mild hypoxemia can be a normal physiologic parameter. At these elevations patients can flunk the PERC rule due to borderline hypoxemia with oxygen saturation levels in the 93-94% range, despite  all other PERC rule criteria being negative. This can result in D-dimer testing and the associated risk of unnecessary CT radiation exposure in the event of a false positive D-dimer.

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How to Call a Consult

17 Mar
March 17, 2016

How to Call a ConsultWhen on shift in the ED we spend more time with a phone in our hand than a laryngoscope. Despite this, we spend a lot more time finessing our laryngoscopy skills than the way we call our consults. Calling an efficient and effective consult / admit can greatly improve our on-shift flow, and therefore happiness. The rest of this post will focus on the art of how to call a consult. Read more →

More Dogma: Epinephrine in Digital Nerve Blocks

03 Sep
September 3, 2015

Digital Nerve BlocksYou are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”.

When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content.

The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback) Read more →

Post Intubation Sedation for Pregnant Patients

10 Aug
August 10, 2015

Post Intubation Sedation in Pregnant Patients

You have just intubated a seizing eclamptic woman who is 34 weeks pregnant. As she is being prepped for transfer to the OB unit for an emergent C-section your nurse asks you what medications you would like for post intubation analgesia and sedation.

You have limited recollection of whether Propofol crosses the placenta, and have legitimate concerns about Fentanyl’s chances of producing a ‘floppy baby’ for the OB team on delivery.

The literature on the most appropriate post intubation analgesia / sedation package for late pregnancy patients is limited. The agents we are the most familiar with in the emergency department for post intubation sedation and analgesia are Fentanyl and Propofol. One reliable mantra for post intubation analgesia and sedation is ‘Fentanyl is the sauce, and Propofol is the oregano’, it would be great to be able to apply this mantra to the pregnant population also.

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