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
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.
WHAT DOES THAT MEAN?
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.
quick hit review in July’s EP Monthly:
1% diclofenac gel (Voltaren):
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
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.
nice idea from a recent JEM article:
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.
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):
Food for thought.
back from vacation with some quick procedural tips via a recent EM Resident article:
HUMERAL INTRAOSSEOUS (IO) ACCESS:
Contraindications (to any IO site):
There you go. Add it to the toolbox.