Archive | September, 2014

great visual: hematoma block

11 Sep

if you have 10 seconds only, check out this great picture for those visual learners from an old EP Monthly article:


if you have more than 10 seconds to spare…


HEMATOMA BLOCK (check out this previous post for another nice review):

  • draw up 10 cc or so of 1-2% lidocaine
  • clean site
  • insert needle into fracture spot, confirmation by
    • ultrasound
    • needle “falls” into the fracture with loss of resistance
    • flash of blood
  • infiltrate 8-12 cc lidocaine
  • wait 5-10 minutes
  • reduce away


References: EP monthly article; picture

Dextromethorphan intoxication

8 Sep

Dextromethorphan (DXM):


Hepatic P450 enzymes into active metabolite dextrorphan.  10% of patients are poor metabolizers.

Time of peak serum concentration is 2-2.5 hours

Half-life for DXM is 1.5-4 hrs.  Half-life for dextrorphan is 3-6 hrs

Receptor activity

  • DXM is an opioid agonist at the brain stem cough center. Can cause respiratory depression, particularly in children
  • Dextrorphan
    1. serotonergic agonist: can cause serotonin syndrome
    2. adrenergic reuptake inhibitor: tachycardia, mydriasis, HTN, diaphoresis
    3. NMDA and glutamate antagonist: behavioral effects ranging from euphoria to complete dissociation. Gait ataxia.


Clinical effects are at plateaus of DXM doses.

  • Mild stimulation at 1.5 mg/kg or 100-200 mg
  • Euphoria and hallucination at 2.5-7.5 mg/kg or 200-400 mg
  • Partial dissociation at 7.5 mg-15 mg/kg or 300-600 mg
  • Complete dissociation at 15 mg/kg or >600 mg


Formulations are often combination medications with:  

  • diphenhydramine,
  • acetaminophen,
  • salicylates,
  • phenylephrine,
  • and pseudoephedrine.


Workup should include labs looking for coingestants like acetaminophen and salicylates. DXM levels are available only at dedicated toxicology laboratories and not helpful.

Treatment of respiratory depression is naloxone IV 0.1mg/kg.  Other than that, treatment is supportive and specific to coingestants.


Submitted by Matthew Kongkatong MD.



Dextromethorphan. DrugPoints summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: Accessed September 4, 2014.

Rosenbaum Chris and Edward Boyer. Dextromethorphan abuse and poisoning: clinical features and diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.

Rosenbaum Chris and Edward Boyer. Dextromethorphan poisoning: treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.

loop drainage with glove cuff

5 Sep

Neat idea from a recent JEM article:loop

THE PROCEDURE: Loop Drain for Abscess I&D:


  • 1 cm incision on perimeter of the abscess
  • put clamp/forceps in to explore, break up loculations
  • push forceps to opposite end of abscess, cut another 1-cm incision down to the forceps
  • grab the loop drain, pull through to first incision
  • tie it off

(check out this previous post for a nice video & review)



since its hard to find a sterile loop drain in the ED…

cut the cuff off of the bottom of a sterile glove, use that as your “loop”


OTHER, less sterile options for loops:

non-sterile glove/cuff

trim a tourniquet


There you go.  Other trick up your sleeve, if you need it.


References: JEM article, picture 1picture

ultrasound for AAA

4 Sep


Bedside ultrasound is the initial imaging modality of choice for identifying the size of the abdominal aorta.


It does not show leak, although if significant blood is present in the abdomen, that may be seen (e.g. positive FAST)


Ultrasound by a trained operator is 90-100% sensitive.


may identify a dissection flap.



abdominal aorta > 3cm define AAA.  Measurement is from outside wall to outside wall. 


Ultrasound may be more difficult in some due to obesity, bowel gas, or tenderness.

Common pitfall: ID-ing the IVC instead of the aorta


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine, Chapter 63 – Symptomatic Abdominal Aortic Aneurysms; Emergency ultrasound imaging criteria compendium. Annals of Emergency Medicine 48: 487, 2006.;; picture; picture 2

tracheostomy complications

2 Sep

There are generally three categories of tracheostomy complications

Immediate after placement, early, and late.

  • Immediate and early happen within 48 hours of placement.
  • Late happens after


the most concerning late complication is tracheoinnominate fistula

  • this is severe with high mortality.
  • may be heralded by small amounts of bleeding in the days prior to a large hemorrhage.
  • Usually it takes about 5 days for a tracheostomy tract to mature.
  • Tracheoinnominate fistula usually occurs in the first three weeks after placement, peaking in the 1st to 2nd week.

Treatment for hemorrhage is pressure

Usually by first hyperinflating the trach tube cuff in attempt to tamponade the bleeding.

If this is unsuccessful, then next is placing a finger in the tracheostomy and applying direct digital pressure by pressing the artery against the manubrium.

Surgical consultation should be immediate.  And tamponade of the artery should be maintained to the operating room.


Other complications may be recurring tracheitis or bronchitis related to tracheostomy tube site infection.

Gauze soaked with 0.25% acetic acid can treat local wound infections.


Submitted by J. Stone.


References: Tintinalli’s Emergency Medicine Chapter 242 Compications of Airway Devices; picture