hyperpronation for Nursemaid’s elbow

nice quick overview in a recent EP Monthly mag. Some quick pearls below:

 

TECHNIQUE:

• one hand holding elbow at 90 degrees
• other hand holds wrist
• hyperpronate the wrist
• voila!

 

DATA:

couple small studies comparing hyperpronation technique vs. supination-flexion reduction

• hyperpronation 94 & 96% successful in 2 studies
• supination-flexion 68 & 69% successful in 2 studies

 

BOTTOM LINE:

hyperpronation seems like a reduction method worth trying, seems pretty successful

 

References: epmonthly article (+ pic from article)

 

visual aid: Seidel sign

 

WORRIED ABOUT A PENETRATING GLOBE INJURY?

look for a Seidel’s sign: leaking fluid from the eye/globe on fluorescein exam

 

VISUAL AIDS:

came across these nice videos on the magical internet, check out the first video if you can only spare a few seconds.  check out the 2nd video for some voiceover and a little more detail.

 

 

References: video 1; video 2

 

ECG lead placement: cheat sheet

always good to know where to hook up the leads

• not only to be able to do it on your own…
• but also handy for checking placement if your ECG looks inexplicably odd (hint: go back and see where the stickers/leads are sitting on your patient’s chest)

 

for the LIMB LEADS:

if you’re lucky, they’re labeled and not faded, with RA (right arm), LL (left leg), etc.

in the UNITED STATES (colors are apparently different in Europe), here’s the mnemonic I learned:

think of it like 4 corners of your torso (where your limbs start):

• smoke over fire (black over red)
• white on right (hey, it rhymes)
• by process of elimination the green lead goes in the one remaining corner of their torso (RL)

in EUROPE, the colors are apparently different, so if anyone has a mnemonic from across the pond, please feel free to share.

 

PRECORDIAL LEADS (V1-V6):

here’s how I remember placement:

• V1 is on the right sternal border, V2 is on the left sternal border: both are ~4th intercostal = nipple line
• V4 is mid-clavicular, so I put it at the lower edge of pectoral/breast under the left nipple
• V6 is mid-axillary, easy enough
• then fill in the blanks: V3 (placed halfway between V2 and V4), then V5 (between V4 and V6)

there you go.

 

References: limb leads picture; european/us lead colors; precordial leads + picture

 

PE rules: what are the common themes?

PERC Rule, Well’s Critera

both are clinical decision rules used to identify patients low-risk for PE

breakdown of each rule set below, but here are some common themes in both rule sets for low-risk patients:

• HR <100
• No prior history of DVT/PE
• No recent trauma/immobilization/surgery
• No hemoptysis
• No clinical signs/symptoms of DVT (e.g. unilateral leg swelling)

there’s what you learned in medical school, coming back in actual clinical practice

So what else does Well’s Criteria look at?

• your clinical suspicion: asks if PE is tops on your differential
• cancer history: treatment within 6 months, or palliative

if you have NONE of these, plus none of the common list from above, then you’re low risk for PE (1.3%)

 

So what else does the PERC rule lookat?

• age: <50 (younger is better, apparently)
• hypoxia: room air 02 sat >94%
• estrogen: no exogenous estrogen (e.g. OCPs) is lower risk

if these 3 things, + the common 5 from above, are negative = low risk

may miss 1-2% of PEs, but suggested these would be low mortality/low clot burden patients

 

10-SECOND TAKEAWAY:

• clinical decision rules are low-risk, not NO risk
• accept some tiny risk of missing something when you use these, at the benefit of not irradiating everyone
• good luck

 

References: PERC rule MDCalc.com; Well’s Criteria MDCalc.com; picture

send your upper GI bleeder home?

2009 study by Stanley et al:

used a decision rule based on clinical and lab values (Glascow-Blatchford bleeding score)

study of 676 people with upper GIB: 105 (16%) had a score of ZERO

 

score of ZERO identified low-risk patients who might be suitable for outpatient management

• i.e. GBS of ZERO have low risk (0.5%) of needing intervention (transfusion, endoscopic treatment, or surgery)

to get a score of ZERO:

• BUN <6.5 mmol/L
• Hemoglobin >=130 g/L (men) or >=120g/L (women)
• SBP >=110 mmHg
• Pulse <100 
• absence of melena, syncope, cardiac failure, or liver disease

no interventions, no deaths in the ZERO GBS score group

2nd phase of study used the GBS score for 491 patients

• 123 scored as low-risk
• 84/123 not admitted
• only 23/84 offered outpatient endoscopy showed up for it – none needed intervention
• 1 died from disseminated (non-upper GI) malignant disease (endoscopy only showed gastritis)
• of the rest, no one got readmitted for GIB or died in 6 mo follow-up

BOTTOM LINE:

upper GIB patients with the following criteria may be considered for discharge and outpatient follow-up:

• BUN <6.5 mmol/L
• Hemoglobin >=130 g/L (men) or >=120g/L (women)
• SBP >=110 mmHg
• Pulse <100 
• absence of melena, syncope, cardiac failure (historic or otherwise), or liver disease

References: article; picture

nebulized naloxone

Nice review in November’s EP Monthly mag by Drs. Hepker & Erickson:

HIGHLIGHTS:

DOSING:

2 mg nalaxone + 3 mL normal saline

placed in standard canister, nebulize away

REMEMBER: repeated or continuous nebs may be needed (half-life of Narcan much less than opiods)

 

SUPPORT:

• 105 case study
  • 23% complete response
  • 59% partial response
  • 19% no response
  • no adverse events, no assisted ventilation
• 26 patient study
  • mean GCS improved from 11 to 13
  • mean RASS improved from -3 to -2

 

DOSING (reminder):

2 mg nalaxone + 3 mL normal saline

 

References: epmonthly.com; picture

video refresher: ED thoracotomy

CRACK TO CURE:

Repost, but a great video by Scott Wiengart, ~35 min, with awesome visuals and some great tips. watched it again myself recently. 

 

TIPS FROM THE VIDEO (for those short on time):

slow is smooth, smooth is fast.

make sure someone else (if available) is still running the code

wear a face-shield & mask; double-glove

INCISION: curve up to armpit (follow rib-line)

CUTTING THE PERICARDIUM: cut anteriorly/medially (the ‘ceiling’); the phrenic is lateral

HOLE IN THE HEART? — put your finger ON (not in) the hole. 

CROSS CLAMP AORTA? run the back of your hand along the posterior ribs, and it should be the first tubular structure your fingers touch.

 

References: weingart EMcrit video