Thoracentesis

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Thoracentesis

General Considerations

Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.

It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.

US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1)  Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.

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March Issue - Annals of B Pod

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March Issue - Annals of B Pod

Spring is here and new beginnings are right around the corner. Step-ups are looming and we will find out the names of our new interns any day. It is time for interns to polish their efficiency, for the R2s to finish their off-service rotations in anticipation of the great variety of the SRU, the R3s to finishing refining their ability to run an effective team. The R4s #fillintheedges of their careers as residents so they can go forth as prepared attendings. In anticipation of these new beginnings, this issue of Annals of B Pod focuses on cases that #fillintheedges.

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Grand Rounds Summary 3/9/2016

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Grand Rounds Summary 3/9/2016

Back Pain with Dr. Summers

Of the more than 2.5 million ED cases of back pain every year, roughly 5% of these actually have an emergent cause. Conventional red flags include:

  • Age >50 or <20 yo
  • History of cancer
  • Immunocompromised
  • HIV
  • Steroid use
  • IV Drug Use
  • Known aortic aneurysm
  • Motor neurologic deficit
  • Urinary retention, bowel incontinence, or saddle anesthesia
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Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

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Lung Ultrasound: Evaluation for Pleural Fluid and Pneumothorax

The Basics

Think about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)

Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from “artifact” or ultrasound waves being affected by phase changes.

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Closing the Gap: Deep Sutures

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Closing the Gap: Deep Sutures

While many wounds are adequately repaired with simple interrupted sutures, not infrequently we are confronted with wounds that require more specialized suturing methods. One such method is deep sutures. Here to answer some questions regarding deep sutures is our wound management guru, and author of the book “Wounds and Lacerations: Emergency Care and Closures,” Dr. Alexander Trott. 

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Annals of B-Pod: Acute Vision Loss

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Annals of B-Pod: Acute Vision Loss

Thinking about the other left lower quadrant

 

The patient is a 74 year-old African-American female with a history of hypertension, coronary artery disease status post drug-eluting stent ×1, former cigarette smoker, and iron deficiency anemia presenting with left-sided vision loss. Patient states that approximately two days ago  she woke up with painless peripheral vision loss of her left eye only. She describes it as darkness in the lateral portion of her left eye. She  reports that her vision returned to baseline throughout that day; only to return when she awoke the next morning. Since that time she endorses persistent vision loss in the left periphery. She denies blurry vision, eye pain, headaches, recent trauma, flashes, and floaters. Furthermore, she also denies dizziness, numbness weakness, dysarthria, dysphagia, fever, chills nausea, vomiting, chest pain, shortness of breath, and palpitations. She reports adherence to her antihypertensive and anti-platelet medications...

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Flights - Un-Break My Heart

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Flights - Un-Break My Heart

It is early October and you are the flight doc in C-pod on a brisk but clear Saturday morning. The day starts out with several challenging patients with vague complaints and has just begun to ramp up in volume when a patient rolls into your pod by EMS, restrained face-down to the cot, covered in feces and urine, screaming about hearing voices. You begin to take report from EMS when, as if by divine intervention, the tones drop and you are dispatched for an inter-facility transfer. You gleefully (almost too gleefully…) give a brief patient sign-out to your staff, grab the blood cooler, and head to the roof...

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Grand Rounds Summary 3/2/16

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Grand Rounds Summary 3/2/16

OB-GYN Emergencies with Dr. McKinney

Case 1: 18 wk patient with vaginal spotting who is Rh- but antibody+

Bedside U/S shows fetal abnormality due to Rh alloimmunization with fetal hydrops. Positive antibody screening on gravid female should warrant obstetric consultation. Rhogam administration within 72 hours of bleeding is important.

Case 2: 40 wk female with gestational DM present with crowning fetus who fails to immediately deliver secondary to shoulder dystocia.

Treatment: stop pushing and avoid traction. Initially attempt hyperflexion of legs and suprapubic pressure to release (McRoberts maneuver). Then consider episiotomy because subsequent maneuvers involve twisting the baby to get shoulder into a different plane. 

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Annals of B-Pod: Approach to the Febrile Infant

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Annals of B-Pod: Approach to the Febrile Infant

Imagine it’s your first moonlighting shift at a small rural community hospital. The nearest referral center for both adults and children is 90-minutes away by ground. The annual census of the emergency department is 15,000 patients per year, of which only 5% is pediatric. There are 2 hours left in your 12-hour shift and your energy is all but spent. You are looking forward to winding down at home after an extremely busy and high-acuity shift when your 35th patient of the day checks in. The patient’s chief complaint is fever. You give yourself an internal fist pump thinking that you’re about to see your 12th viral URI of the day and that you’ll be in-and-out of that room no in time. In the midst of your premature celebration you scan the nursing note and see the age of the patient: 6 weeks…You’re hopes of a quick and easy disposition suddenly melt away leaving you with many more questions regarding this patient’s care than answers…You muster your remaining energy and make your way toward the patient’s room.

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Take My Breath Away! Evaluation of Shortness of Breath in the ED

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Take My Breath Away! Evaluation of Shortness of Breath in the ED

There are many chief complaints in the emergency department that can be less than satisfying (*cough* abdominal pain *cough*).  Sometimes such patients end up having a completely benign examination, no significant risk factors found on history, and an encounter that leaves you shrugging your shoulders and telling the patient “bellies will do that sometimes, we don’t always find out why.”

Of course, this is all anecdotal, but the chief complaint on this month’s episode seems to have a more consistent presence of pathology with a wide range of severity.  With such heterogeneous pathophysiology we turn to the mind of Dr. Stewart Wright to discuss the initial approach to the patient with shortness of breath (SOB)...

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A Lonely Road - Recap and Expert Commentary

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A Lonely Road - Recap and Expert Commentary

A couple of weeks back, we kicked off our “Flights” portion of our Air Care Orientation Curriculum.  Dr. Latimer outlined a challenging patient case for use to consider and an excellent discussion ensued.  As a reminder of the case, here’s how it was posed:

Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.

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The Urine Drug Screen - Know Thy Limitations

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The Urine Drug Screen - Know Thy Limitations

We are all guilty of ordering them in the ED, but do we really know what we’re ordering?

The Implications of the Urine Drug Screen

1 literature review looked at 7 different retrospective studies describing a total of 1,405 patients and found the urine drug screen did not affect the management of any of these patients while in the emergency department.  However, the data from the UDS can affect a patient’s clinical care outside of the Emergency Department.  For example, if a patient requires psychiatric inpatient care, initial knowledge of drug abuse could affect this patient’s etiology of illness or rehabilitation plan.

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Grand Rounds Recap 2/10/16

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Grand Rounds Recap 2/10/16

R4 QUARTERLY SIMULATION with Drs. Curry, Loftus, Ostro and Strong

We presented a case of a 42 y/o female who presented with altered mental status, hypotension and bradycardia. She was ultimately found to have an unintentional labetalol overdose which she had been taking PRN for headache.

Beta-Blocker Overdose Take-Home Points...

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Grand Rounds Recap 2/3/16

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Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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