Grand Rounds Recap 4.18.18

Grand Rounds Recap 4.18.18

This week we got a refreshing look at soft tissue ultrasound from our US guru Dr. Stolz. We then moved to the opposite end of modern imaging with the rarely indicated but intermittently very useful KUB by Dr. Skrobut. Drs Kiser and Ventura battled it out in a CPC case of pyloric stenosis then the R4s ran a simulation and small group on global health pathologies.

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Grand Rounds Recap 3.28.18

Grand Rounds Recap 3.28.18

This week's Grand Rounds opened with Dr. Ludmer giving Morbidity and Mortality conference. Sports Medicine Dr. Betz then took on the common chief complaint of ankle pain, and described the evidence-based management and common ankle sprain mimics. Dr. Shaw discussed basics on tracheostomies and Dr. Renne closed out Grand Rounds with his approach to the judicious use of IV fluids in septic shock. 

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EM Diagnostics: Pleural Fluid and Ascitic Fluid Analysis

EM Diagnostics: Pleural Fluid and Ascitic Fluid Analysis

Paracentesis and thoracentesis are relatively common procedures in the Emergency Department but the analysis of the fluid can always but a touch confusing.  In this post, PGY-1 Dr. Michael Klaszky walks us through the analysis of pleural fluid and ascitic fluid.

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Thoracentesis

Thoracentesis

General Considerations

Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.

It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.

US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1)  Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.

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Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

The Basics

Think about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)

Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from β€œartifact” or ultrasound waves being affected by phase changes.

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