Category: Uncategorized

Intracranial Hemorrhage

  • ABCs first –> intubate if needed
  • BP control <140 (labetolol pushes, nicardipine drip)
  • Dexamethasone 6mg q6h
  • Brain MRI w and w/o –> brain mass protocol to assess for malignancy
    • Consider full body CT scan to assess for primary
  • HOB 30˚
  • NSGY and NEURO consult
  • ICU for q1h neuro checks

Ultrasound Tips mostly From Core US

Peter Weimersheimer (Cardiac):

Basics:

  • Depth – Make sure that the image you’re trying to see is as big as you can make it.  Don’t have any wasted space in your clips or images.
  • Gain – Make sure your image is bright enough.  But don’t over gain!
  • Exam type – If you’re doing a FAST exam, don’t scan in the “lung” setting. 
  • Video clips – Be conscientious of the clips and images you take.  Focus on the thing you want to record and record a long enough clip of it, but also don’t record multiple clips of subpar exams.

Specific exams:

  • DVT – Make sure that the vein you’re evaluating is actually a deep vein. Deep veins paired, while superficial veins may be solitary.  Also, don’t confuse a lymph node for a DVT.
  • FAST exam – Slow sweeps of the regions your evaluating.  Fast sweeps can miss subtle fluid collections. Don’t forget to look at the inferior pole of the kidney/caudal tip of the liver interface on the right side.  Be careful with the seminal vesicles in the pelvis.
  • Intrauterine pregnancy (IUP) – Make sure that gestational sac is actually inside the uterus.
  • Thorax – Make sure to look at the back of the thorax when evaluating your patient with suspected pneumonia
  • Aorta vs IVC – To identify the IVC, first find the right atrium then look for the thing coming off of the right atrium. That’s your IVC.  Know your left and your right.  Most of the time, the IVC will be on the patient’s right.  Also, put color flow on it.  The less pulsatile one is the IVC.
  • BEN SMITH on AORTA/RENAL:
  • If you think you see mild hydro, use color flow to differentiate between mild hydro and prominent renal vessels
  • Scan from the back; the ribs are farther away from each other back there so may get better windows.
  • We aren’t good at finding the actual ureteral stone, but were pretty good at hydro
  • For getting past bowel gas when looking at the aorta – start up high where there is less gas (epigastric). Then when you come up on gas, use other hand to apply steady pressure (often 30-60 seconds). Use curvilinear probe, hurts less than the phased array.
  • Transhepatic view of aorta – not bad for aneurysm, but not great for dissection
  • We are good at looking at the aorta as long as we can actually see the aorta. Research that show great accuracy of bedside sonographic aorta exam only included studies where the aorta was able to be visualized.
  • Find the beating thing first.
  • Use lots of gel, and lot of pressure to get your view.
  • Get your ultrasound beam parallel with the heart.
  • Start your exam with your patient in the left lateral decubitus position.
  • Do one maneuver at a time (rotate, fan, rock, etc).
  • Start with the probe at the clavicle/sternal interface, slide down until you see the heart.
  • You don’t always need all the 4 views of the heart.
  • If ventricle is round, subtle hand rotations will fix.

Steroids for CAP

Steroids For CAP Patients Who Are Admitted

Current data demonstrate that for adult patients with severe community-acquired pneumonia corticosteroids reduce morbidity and mortality (1-3). For pediatric patients and adults with non-severe CAP who are admitted to the hospital, corticosteroids appear to reduce morbidity, but not mortality.

The use of corticosteroids has also demonstrated to cause a reduction in early clinical failures, time to clinical cure, length of overall hospital stay, total ICU days, development of respiratory failure or shock, and rates of pneumonia complications in adults with severe CAP.

It must be noted that the data for children is based on small studies and the mortality event rate was low.

Most adult studies used a corticosteroid dose equivalent to 40 – 50 mg of prednisone/day for 7 days.

A December, 2017 Cochrane review found that for adults with severe CAP, the number needed to treat with corticosteroids was 18 patients to prevent one death (1).

(Note that studies of neonates, Pneumocystis jiroveci pneumonia, and HIV patients were excluded from meta-analyses evaluating this topic).

References:
(1) Seagraves T, et al. Ann Emerg Med. 2019 Jul;74(1):e1-e3.
(2) Pliakos EE, et al. Chest. 2019 Apr;155(4):787-794.
(3) Stern A, et al. Cochrane Database Syst Rev. 2017 Dec 13;12:CD007720.

Capacity

Rob Orman – ER Cast Newsletter

I feel that the patient has decision-making capacity. [He/She] demonstrates ability to understand the current situation and is able to communicate a choice for what [he/she] wants to do. [He/She] expresses understanding of benefits, risks, and alternatives and is able to make logical and rational choices, even though they are not in line with my recommended medical direction. There is no evidence of intoxication or altered mentation which would preclude normal cognitive function.