resuscitation in pregnancy

via a nice recent post at emDocs.  Click through for the whole read, but if you only have 30 seconds to spare…

QUICK PEARLS:

put your IV above the diaphragm (uterus compresses IVC)

 

remove fetal monitoring equipment prior to defib

 

if you need to RSI, etomidate + succinylcholine is safe

• (Epocrates lists both as pregnancy “C”, though if you need an airway, benefit probably outweighs risk)
• “Etomidate will cross the placental barrier, but causes less fetal respiratory suppression than other medications, and succinylcholine does not cross the placental membrane.”

 

peri-mortem c-section: by 4 MINUTES INTO CODE

• if you don’t know how far along, uterus at level of umbilicus is probably ~20-24 weeks
• check out this old post for a refresher on the procedure

 

IF YOU HAVE ANOTHER 30 SECONDS:

extra-thinking mnemonic for pregnant code: BEAU-CHOPS

B=Bleeding/DIC

E=Emboli: coronary, pulmonary, amniotic fluid

A=Anesthetic Complications (aspiration, local anesthetic toxicity)

U=Uterine Atony

C=Cardiac Disease i.e. cardiomyopathy, aortic dissection

H=Hypertensive disease i.e. preeclampsia-eclampsia

O=Other-think about the Hs and Ts

P=Placental abruption, previa

S=Sepsis

References: emDocs post, peri-mortem c-section refresher; picture

strength in numbers: aortic dissection

just to scare you, and/or keep you on your toes (from the Oct/Nov EMRA mag):

5% of acute aortic dissections will NOT have associated pain

 

38% will NOT have a widened mediastinum on CXR

 

12% will have syncope

 

2-5% have concurrent MI (proximal dissection into the RCA)

 

up to 30% have acute neuro deficits

 

References: EMRA article, picture

 

suture through Steri-strips

nice trick for wound repair via January’s ACEP Now, especially if the patient has thin skin:

 

SUTURE THROUGH STERI-STRIPS:

basic idea: if the skin is so thin that suture would just tear through it when adding tension to approximte the wound edges, use the steri-strips to “thicken” the skin, so you can now anchor the sutures without tearing through anything.

2 ideas:

1) use the Steri-strips to bring the wound together, then suture through ‘em

2) don’t use the Steri-strips across the wound, but rather just as an added layer near the wound edges to give a “thicker skin” to suture through.

Neat ideas. Add it to the toolbox.

 

References: ACEP Now article + pictures; original 2011 article for idea 1

pertussis: quick hits

(Should’ve been posted earlier, but didn’t make it up somehow.  Here it is now, though, for your learning pleasure).

Pertussis is bad and increasing – it kills ~300,000/yr in non-vaccinated places & can cause serious systemic issues like vert dissection, etc.

- B. pertussis starts like a viral URI (cough, rhinorrhea, malaise)

- incubation period is about a week or so, and it is very contagious by air particles (use precautions!)

- more common in older adults who have waning immunity.

- The danger is for passing it to infants who have not immunity.

- In older adults, it is persistent cough lasting ~3-4 weeks and getting worse from week 1 to 2. Often paroxysmal.

- In infants, it is flu-like symptoms followed by paroxysmal cough with whooping inspiration against a closed glottis.

- Protect against pertussis with DTaP or Tdap.

- Test for pertussis with PCR (earlier) or culture (later)

- Treat pertussis early if possible, use Azithromycin

- Treat in those with high suspicion, those exposed, and those with suspicion with infants at home.

 

Submitted by J. Stone.

 

Sources: uptodate.com;  EMRap podcast discussion; picture

the power of placebo

from a great podcast on The Placebo Paradox from SMART EM:

worth a download and a listen, but for those in a time crunch…

QUICK PEARLS:

surgery, e.g. knee arthroscopy (debridement/lavage) vs. sham procedure: similar effects

two placebos are better than one

brand name placebos work better

no-cebos: negative effects happen, too (swelling, rash, diarrhea)

red placebos -> stimulants; blue placebos -> sedatives

 

accupuncture spot P6, for nausea (doesn’t work if done while under anesthesia; but works better than sham accupuncture at another site)

 

placebo is a deception; patient doctor bond is being compromised (endorsed the idea of a ‘magic pill’), create the expectation for the next visit

 

patient with URI symptoms want [to know]:

1. how bad it is
2. is it dangerous
3. what to do next
4. what to expect
5. how long will it last
6. antibiotics  — much lower on the list than most of us expect

 

but there is a meaning response. patients care:

• whether they were tended to
• whether they were listened to
• whether the doctor cared
• validation
• medications can sometimes be a surrogate for this (not the ideal, but something we all do at times)

 

the doctor-patient connection is the key

 

References: Smart EM podcast; picture

visual aid: cardiac ultrasound (echo)

Came across a couple of sites that have a good set of visual aids for what you’re expecting to see on your bedside cardiac ultrasounds.  

(via the Yale Atlas of Echocardiography–this site has some great illustrations that help visualize the anatomy as well)

parasternal long axis view

short axis view

(via sonoguide–some simple illustrations that you’d do for a FAST or a code, though they have a more detailed cardiac section as well)

subxyphoid view

 

Both sites have some more extensive sets of photos and explanations of multiple cardiac views, so check ‘em out if you have a few extra minutes.

 

References: Yale atlas; sonoguide

quick reference: what counts as Health-care Associated Pneumonia?

RISK FACTORS:

• antibiotics within 90 days
• current hospitalization >= 5 days
• high frequency of antibiotic resistance in the community/hospital unit
• presence of risk factors for HCAP
  • hospitalization >=2 days within 90 days
  • nursing home/extended care facility resident
  • home infusion therapy (incl. antibiotics)
  • chronic dialysis within 30 days
  • home wound care
  • family member with multi-drug resistant pathogen
• immunosuppressive disease/therapy

This came up recently on a search to see if health care workers would be considered at risk for HCAP (technically, it appears ‘no’), though a brief search did not find much in the way of definitive statements. Anecdotally, practice patterns seem to differ.   Any discoveries/opinions appreciated in the comments section!

 

References: medscape 1, 2; thoracic.org; picture