Pediatric Abdominal Ultrasound

Pediatric Abdominal Ultrasound

After a long shift in the adult ED, jam packed with patients presenting with abdominal pain, your looking forward to a brand new day in the Peds ED.  Your first patient, however, gives you PTSD-like flashbacks to the previous days shift.  

Alice is a 8 year old girl who developed abdominal pain last night.  Her parents thought that she would be okay waiting until morning, that the pain would pass in the night.  On waking this morning, however, the pain was still there.

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CT Abdomen and Pelvis - Hollow Viscus

CT Abdomen and Pelvis - Hollow Viscus

It's weird how you get runs of patients in the ED.  Some days it seems like it's nothing but wall-to-wall low risk chest pain, altered mental status, or back pain.  Today (and a lot of other days), it's abdominal pain.  Scanning the board you see seemingly nothing but Level 3 acuity patients with the chief complain of "Abdominal pain."  Out of the scores of patient's, you seen so far, the last 2 worry you the most:

Andrea is a very pleasant 20 year old student from a local college.  She came in after having symptoms of right lower quadrant pain over the course of the past 8-12 hours.  She didn't recall any migratory symptoms but does endorse a lack of appetite, nauseousness, 2 episodes of vomiting (started after the pain), and steadily worsening pain.

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Grand Rounds Recap - 4/29/15

Grand Rounds Recap - 4/29/15

Morbidity and Mortality Conference with Dr. Stull

1. Pericardiocentesis tips and tricks

  • Your needle should be at a 45 degree angle when entering the chest at the xyphoid process, aim to the L shoulder/scapula
  • Use a spinal needle and keep the stylet in while entering the skin in order to prevent needle clogging
  • Keep head of bed at 30 degrees to encourage the fluid to drain inferiorly
  • Can attach an EKG lead to the needle by an alligator clip. You will get an ST elevation in that lead if you hit the myocardium
  • Can use an A.line kit to place a catheter into the pericardium for continuous drainage
  • US probe position: subxyphoid
  • How to Video on TamingtheSRU - http://www.tamingthesru.com/blog/acmc/pericardiocentesis
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Field Amputation

Field Amputation

Hey, everybody! Today we are going to talk about field limb amputation.

I know what you are all thinking… No, I’m not crazy. Yes, you’ll probably never do one. No, this is not a common procedure. You just might, however, be in a situation on Air Care where knowing how to correctly perform this procedure can safe a life. 

First, let’s provide a little background on the pre-hospital limb amputation. The procedure itself has gained much more press in the FOAMed world and the emergency medicine and pre-hospital literature since the 2010 earthquake in Haiti during which early physician responders were faced with large numbers of patients trapped under debris and few responders with familiarity or basic working knowledge of the procedure (Lorich et al, 2010). A few of case reports and articles surfaced around this time and the field amp even made an appearance in an episode of the popular television show ‘Greys Anatomy’ in 2011. 

So I was told… 

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Flights - A Pain in My Heart

Flights - A Pain in My Heart

You are the Pod doc overnight on a particularly quiet Sunday night.  You have been looking for an excuse to leave the pod and do anything other than treat abdominal pain for the past several hours when the tones drop.  You thank whatever celestial being you believe in and grab the blood and run out of the department full of glee.  In route to the helipad you are told it is a Code STEMI.  At this point, even that seems more interesting than sitting in C Pod.

You buckle into the helicopter and take a quick flight to the outside hospital.  You grab a set of gloves and unload the cot carefully and walk inside.

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Grand Rounds Recap - 4/22/15

Grand Rounds Recap - 4/22/15

Oral Boards Practice Cases

Case 1 - 22 yo F in a "coma" with normal vital signs. Not responding to Narcan and Dextrose. Found in a garage. On exam, she has sluggish and dilated pupils. pH 6.98, pCO2 29, bicarb 2

High concern for toxic alcohol ingestion: consult DPIC and nephrology for dialysis

  • Fomepizole is the antidote for ethylene glycol only
  • Can use ethanol drip to treat both ethylene glycol and methanol
  • Replace folate aggressively and early 
  • Methanol is metabolized to formic acid, if you give folate you can prevent methanol from going down the formic acid pathway
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Annals of B-Pod Spring Issue

Annals of B-Pod Spring Issue

The Spring Issue of Annals of B-Pod is hot off the presses!

Who gets antibiotics in COPD? Does that back pain patient have discitis? What causes pancytopenia anyhow?  Answers to these questions and so many more in this months issue of Annals of B-Pod.  Click on the image below for the full pdf.

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Flights - A Blow to the Head Recap and Expert Commentary

Flights - A Blow to the Head Recap and Expert Commentary

Thanks to everybody who commented and contributed to the discussion on our last "Flight!" If you missed out on the case, check it out here.  We had a great discussion which we have recapped here.  Take a look below and a listen to the commentary provided by Dr. Bill Hinckley in the embedded podcast.  Look for our next flight to lift off in the next couple of weeks!

What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?

This first question sparked quite a bit of debate within the community.  Everybody agreed that this patient requires sedation, intubation, and more sedation.  There was, however, some significant differences in how the providers would go about attaining adequate sedation.

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Grand Rounds Recap - 4/15/15

Grand Rounds Recap - 4/15/15

Ocular Emergencies with Dr. Titone

Blood supply to the eye is from the Internal Carotid and drainage is through cavernous sinus.  Bony eye septum is an improtant structure that separates the superficial structures from the deeper structures that have direct communications with the brain.

Key historical factors: recent eye procedures, eye drop use, contact lens use, occupational history, UV ligh exposure

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Grand Rounds Recap - 4/8/15

Grand Rounds Recap - 4/8/15

AirCare Grand Rounds

1. Indications for T pod

  • Blunt trauma + unstable pelvis
  • Blunt trauma + shock + pelvic tenderness to compression
  • Blunt trauma + shock + AMS/inability to evaluate pelvic pain

In patients with blunt trauma who are in shock and have AMS, incidence of pelvic fractures is 10%. In patients who die of blunt trauma during transport, open book pelvis fracture is the #1 cause of death (according to our own QI data)

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The Cognitive Autopsy

The Cognitive Autopsy

We are in a thinking profession.  

An outsider looking in on our profession may see procedures and action as the defining characteristics of the practice of Emergency Medicine.  But, reflecting on the attributes of the best EM docs I’ve worked with, their procedural excellence isn’t what stands out.  Thinking back on the great physicians I have met and worked with, the ones I strive to be like every day, it is their ability to think, lead, and educate that sticks with me the most.  

And, it turns out I’m not the only one who might see it like this…

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Vascular Ultrasound - Aorta & Lower Extremity Veins

Vascular Ultrasound - Aorta & Lower Extremity Veins

It's a frosty Easter morning and the ED is "q!&%t," all except for the 2 patient's turned over to you by the night ranger.  You greet the first patient, a 75 yo M complaining of flank pain - probably a kidney stone you think to yourself as you walk in to the room.  Walking into the room, you see the patient rolling around on the stretcher (as one would expect from those with a stone jammed in the UVJ), but something about his presentation strikes you as odd - a bit of diaphoresis, clammy pale skin.  It could just be pain, but the specter of a ruptured abdominal aortic aneurysm still looms large in your differential diagnosis.  You quickly exit the room, grab the ultrasound machine and head back in to take a look at his aorta...

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Flights - A Blow to the Head

Flights - A Blow to the Head

You’re working as the Pod-Doc, having just taken the radio from the off-going UH-doc, you just finish admitting the patient in C40 for NSTEMI when the tones go off.

“Air Care 1 and Pod Doc respond to a scene for motorcycle crash, Northern Kentucky”

You call the B-Pod attending, sign out the pod, grab the blood from the blood cooler and head to the helipad.  Flying over the river, landing at a local firehouse’s parking lot you hop out of the back of the helicopter and head to the awaiting squad.

Your patient is a 29 year-old male who was riding his motorcycle (without a helmet) on a local country road.  Coming around a blind corner he unexpectedly found a car stopped in the middle of the road.  Striking the car from behind at ~35mph, he flew over the handlebars and impacted the back of the car.

On EMS’s arrival he was initially unconscious, but since their arrival has become increasingly combative

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Grand Rounds Recap - 3/25/15

Grand Rounds Recap - 3/25/15

Mortality & Morbidity Conference with Dr. Bohanske

Remember that sometimes the thing a patient needs most is a specialist (i.e surgeon), especially trauma patients

  • Sharps in hectic situations, such as any resuscitation, are dangerous not just for the patient but also for providers as this is one of the most common situations leading to bloodborne pathogen exposures
  • Remove sharps from the field anytime you do not need them and always be responsible for your own sharps to keep your team safe
  • Keep in mind that early predicators of hemorrhagic shock are pulse and mental status/anxiety as BP changes are later indicators
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Laryngoscopy - A Definition of Terms

Laryngoscopy - A Definition of Terms

There can be some confusion with regards to the terminology surrounding laryngoscopy.  The term "video laryngoscopy" can be used imprecisely without specific attention paid to the geometry of the blade containing the video camera.  The geometry of the blade, however, is crucially important as the biomechanics of laryngoscopy differ substantially depending on whether a standard geometry (Macintosh or Miller) blade or a hyperangulated blade is used.  Below you will find specific definition of terms with regards to laryngoscopy and a video demonstrating the differences between direct laryngoscopy, standard geometry video laryngoscopy, and hyperangulated video laryngoscopy.

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Grand Rounds Recap - 3/18/15

Grand Rounds Recap - 3/18/15

Evidence-Based Emergency Medicine: Vent Management with Drs. Axelson & Scupp

The term Acute Lung Injury (ALI) is being phased out and instead Acute Respiratory Distress Syndrome (ARDS) is now graded mild, moderate, and severe depending on the PaO2:FiO2 ratio

The median onset of ARDS after presentation to the ED was 2 day but could be anywhere from 5 hours to 5 days

ARDS Net was a foundational trial in ventilator management and was a triall of tidal volume and plateau pressures.  The primary end point, mortality, was reduced by >20% when folks were on a low TV (6cc/kg) and lower PP (25-30 mm Hg).

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Grand Rounds Recap - 3/11/15

Grand Rounds Recap - 3/11/15

Health Care Disparities with Dr. Ford

There is a well established distrust of the medical system by minorities, especially African Americans. The historic causes of this distrust are widespread and seen in nearly all stages of American Healthcare. A great resource is Medical Apartheid by Harriet Washington. Some key examples of the use of AA in medical advances: 

1800s: Slaves referred to as "clinical material" in medical schools and journal publications. Slave bought and used for experiments and experimental surgeries including the first successful vesicovaginal fistula repair (caused by forcep deliveries) which was done without anesthesia. 

1900-1930: "malaria therapy" with fatal falciparum used to try and treat syphilis. Tuskeegee experiments- subjects recruited under false pretense of "free testing and medical treatment" for syphilis experiment with no intention to treat despite PCN being widely available. "The future of the negro lies in the research laboratory..." Patients were offered a free burial when they died from the disease so that an autopsy may be performed. "as I see it, we have no further interest in these patients until they die..."

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Soft Tissue Neck Radiographs

Soft Tissue Neck Radiographs

The soft-tissue neck radiograph can be an extremely useful tool in a variety of clinical situations. These include: epiglottitis, croup, retropharyngeal abscesses, and localization of airway foreign bodies. 

However, like any diagnostic tool, the soft tissue neck x-ray’s usefulness depends on knowledge of the relevant anatomy — particularly the normal size and appearance of various airway structures — as well as a systematic approach to each radiograph. We will discuss both the anatomy and radiographic approach in this blog post.

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EMS Recertification Requirements

EMS Recertification Requirements

Often times during the EMS continuing education courses we teach, we get questions about recertification requirements for both our state and National Registry certifications.  This podcast is designed to summarize the various recertification requirements as well as discuss the National Registry Transition from EMT-Paramedic to Paramedic.  While much of the discussion focuses on these issues relating to Paramedic certifications, the same principles can be applied to recertification requirements for other levels of pre-hospital providers.  For a complete set of recertification requirements we refer Ohio providers to the Ohio EMS website: ems.ohio.gov.  For details about the National Registry’s requirements for re-certification, we refer everyone to their website: nremt.org.   

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