Tamingthesru
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.
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 “artifact” or ultrasound waves being affected by phase changes.
The Urine Drug Screen - Know Thy Limitations
We are all guilty of ordering them in the ED, but do we really know what we’re ordering?
The Implications of the Urine Drug Screen
1 literature review looked at 7 different retrospective studies describing a total of 1,405 patients and found the urine drug screen did not affect the management of any of these patients while in the emergency department. However, the data from the UDS can affect a patient’s clinical care outside of the Emergency Department. For example, if a patient requires psychiatric inpatient care, initial knowledge of drug abuse could affect this patient’s etiology of illness or rehabilitation plan.