quick reference: opiod conversion

1 Sep

for a quick sense of what is an equivalent dose across different opiates:

  • morphine 10 mg IV
  • hydromorphone 1.5 mg IV
  • fentanyl 200 mcg IV


  • hydromorphone 7.5 mg PO
  • oxycodone 15-20 mg PO
  • hydrocodone 30-45 mg PO
  • codeine 180-200 mg PO

References: e-med journal article; emedicine; picture

SVC Syndrome

27 Aug


Your next patient is a 70 yo M with neck swelling and syncopal episode, who said he “felt like couldn’t breathe” when bending forward, then passed out. 

Vital Signs – WNL

Physical exam – Awake, ambulating male with chest wall venous distention, b/l neck swelling, facial plethora when leaning forward and trace peripheral, LE edema. 



Superficial venous distention in superior vena cava syndrome  —>



Imaging – In ED, CT chest and neck (w/ contrast) to evaluate for obstructing mass (e.g. something compressing the SVC)


Etiology – In the preantibiotic era, syphilitic thoracic aortic aneurysms, were frequent causes of the SVC syndrome.  More recently, intrathoracic malignancy is responsible for 60 to 85 % of cases of SVC syndrome.  Non-small cell lung cancer (NSCLC) is the most common, accounting for 50 %  of all cases.

Clinical Manifestations – Interstitial edema of the head and neck is visually striking, but generally of little clinical consequence.  However, edema may narrow the lumen of the nasal passages and larynx –> dyspnea, stridor, cough, hoarseness, and dysphagia.  Cerebral edema can also occur (not awesome).

Cardiac output may be diminished transiently by acute SVC obstruction, but, within a few hours, blood return is reestablished by increased venous pressure and collaterals. Hemodynamic compromise, if present, more often results from mass effect on the heart than from SVC compression.


Submitted by Christina Brown.


References: Up to Date: malignancy related SVC syndromeWilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.SCHECHTER MM. The superior vena cava syndrome. Am J Med Sci 1954; 227:46.Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cava syndrome. The myth–the facts. Am Rev Respir Dis 1990; 141:1114.Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37.Chee CE, Bjarnason H, Prasad A. Superior vena cava syndrome: an increasingly frequent complication of cardiac procedures. Nat Clin Pract Cardiovasc Med 2007; 4:226.picture

topical NSAIDs

13 Aug

quick hit review in July’s EP Monthly:


topical NSAIDs:

  • as effective as oral NSAIDs for pain relief (NNT for 50% pain relief with topical gel = 11)
  • adverse GI side effects less common
  • risk of renal injury not clearly defined, but less systemic absorption (6-10% vs. 85% oral)


1% diclofenac gel (Voltaren):

  • typically QID, up to 32 g/day
  • 100g tube costs ~$45  (the 1.5% solution costs way more)



Worth knowing about, especially in those with significant GI issues taking NSAIDs, with focal musculoskeletal issues.  Keep the cost in mind, though.


References: EPmonthly mag + picture



deep tendon reflexes: which test for which nerve root?

11 Aug

Some quick reminders and visual aids on which reflexes test which nerve roots:

C5 – Biceps

C6 – Biceps, Brachioradialis

C7 – Triceps

L4 – Patellar (knee jerk)

S1 – Achilles (ankle jerk)


This NYU site has some good pictures for each tendon reflex, but here’s a quick & dirty picture for those short on time:



There you go.  Add it to the mental rolodex.


References: neuroexam.com, NYU neuro exam site, picture

tissue adhesive for fingertip avulsions

3 Aug

nice idea from a recent JEM article:


The Idea:

  • distal fingertip avulsions bleed, hard to dress
  • variable efficacy/availability of bandaging/surgicel/lido+epi/etc
  • gluing it is quick, cosmetic, and even a bit antimicrobial


The Procedure:

  • irrigate well, as usual
  • digital block might help (for irrigation, and ’cause the adhesive will sting a bit)
  • no ointments before or after (will break down the adhesive)
  • tourniquet, direct pressure/milking, elevation — to staunch bleeding
  • apply layer of tissue adhesive
  • let dry, apply another layer
  • let dry, apply another layer


Might consider this trick from a previous post to accelerate drying, especially if you didn’t quite stop the bleeding completely.


Boom, there you go.  


References: JEM article; picture

strength in numbers: subarachnoid hemorrhage

30 Jul

via a recent EP monthly article on acute SAH vs. traumatic tap:


sensitivity of CT for diagnosing aSAH: 93% (95% CI 89-96%)

sensitivity of CT  within 6 hrs of headache onset: 100% (95% CI 97-100%)

sensitivity of CT beyond 6 hrs: 86% (95% CI 78-91%)


traumatic taps in up to 30% of LPs


one study (caveats: required dx of aneurysmal aSAH on CTA, and 8/15 SAH dx by LP were missed on initial CT read):

  • cutoff of <2000 x 10^6/L  CSF RBCs: 93% sensitivity (CI 66-99.7%)
  • cutoff of <2000… RBCs + no xanthochromia: 100% sensitivity (CI 74.7-100%)
  • only 15 cases of aSAH diagnosed by LP at 12 academic centers in 10 years
  • interesting, but not practice changing just yet


Food for thought.


References: epmonthly article, picture

Humeral IO

28 Jul

back from vacation with some quick procedural tips via a recent EM Resident article:



  • proximal humerus
  • higher flow rates vs. tibia (~ 2x)
  • closer proximity to central circulation


Contraindications (to any IO site):

  • unhealed fracture
  • active soft tissue infection
  • previous IO attempt within 48 hrs
  • inability to find landmarks
  • joint replacement/prosthetic


The Procedure:

  • Positioning (3 possibilities):
    • palm over the umbilicus
    • flexed arm behind back (i.e. palm “under” the umbilicus) — useful during CPR
    • elbow extended, adducted, hyperpronated (i.e. straight arm by side, hyperprone)

  •  Placement:
    • palpate greater tubercle
    • feel surgical neck
    • pick site 1 cm above surgical neck
    • aim 45 degree angle towards contralateral hip

There you go.  Add it to the toolbox.


References: EM Resident article + picture; humerus picture




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