December 2, 2020

Take Home Points
  • Be sure to consider mesenteric ischemia in any elderly patient with abdominal pain or lower gastrointestinal (GI) complaints.  Remember, the presentation can be tricky to find and they may have a reassuring abdominal exam.
  • Ask about artherosclerotic risk factors, history of cardiovascular disease including atrial fibrillation and prior embolic events, and a history of intestinal angina to help clue you in to the diagnosis.
  • Lab abnormalities could include leukocytosis, lactemia or elevated d-dimer.  But normal labs cannot exclude this disease.
  • The money is in the CTA.  Get it as fast as possible because time is bowel.
  • Consult your surgeons and interventional radiologists eary, because again TIME IS BOWEL

November 19, 2020

Background Information: Central venous catheterization is a common procedure performed in the ICU for the purposes of drug administration and resuscitation. The subclavian vein is the more preferred access site given its fixed puncture location, ease for nursing access and low incidence of infections.1 Landmark guided catheterization has a widely variable success rate and has been shown to increase the risk of complications such as hematoma formation and pneumothoraxes.2,3 The use of real-time ultrasound guidance has thus led to more central lines being placed in the internal jugular and femoral lines, however there is substantial debate regarding its use in subclavian vein catheterization.4,5 The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture.

November 16, 2020

Background Information:

US vs Landmark for Radial Arterial LinesUltrasound guided peripheral and central venous access has become more common while simultaneously decreasing complications and increasing first pass success. Landmark guided palpation has historically been considered the standard of care when placing arterial lines, however the use of ultrasound is challenging that notion as anatomic landmarks are not helpful in 30% of patients.1 Additionally, increasing obesity and hemodynamic instability can make radial arterial line placement even more difficult when using landmark-guided palpation alone. The literature comparing the different methods of arterial line placement is limited to two prospective studies. The first assessed second- and third-year emergency medicine residents while the second study evaluated only four emergency medicine attendings, all with extensive ultrasound training and experience.2,3 The authors of this study sought to compare radial arterial line placement using ultrasound vs landmark guided palpation performed by novice emergency medicine interns with respect to overall success.

November 12, 2020

Background: The well-established, standard treatment for acute appendicitis is surgical appendectomy.  However, recent research has challenged the dominance of the surgical approach in looking at antibiotics alone. The available literature on non-operative treatment of appendicitis (NOTA) has important limitations: exclusion of patients with appendicoliths, small sample size and predominance of open appendectomy over laparoscopic appendectomy. While data on NOTA is intriguing, it is clear that additional studies are needed.

November 11, 2020

Take Home Points
  • Watch for continued bleeding in excess of 500 ml or bleeding that is “more than normal.” Call it postpartum hemorrhage and start resuscitation
  • Call your obstetric and/or surgical consultants early as operative intervention is often required
  • Replace intravascular volume with blood products
  • Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications
  • Consider the development in DIC when patients continue to bleed despite appropriate management