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AKI vs lab error: pitfalls in creatinine measurement

The Jaffe reaction, named for 19th century German biochemist Max Jaffe, is a colorometric assay used by most every clinical lab to measure creatinine. In an alkaline medium, creatinine reacts with picric acid to form a red colored compound; the amount of color change is proportional to the level of creatinine. Increases in creatinine makeRead more

Proceed with caution: Pumps

CAUTION Messing with a pump is an easy way to draw the ire of your nursing colleagues. There are ways to mess this up, and every change in rate needs to be charted. If you’re going to start a drip or change a drip rate, make sure you are communicating clearly with the nurse caringRead more

Pressure Transducer Setup

There are better tutorials on how to set up a pressure transduction line. This tutorial specifically addresses the equipment available in the resuscitation bays at Mount Sinai. You need: (1) Bag of normal saline (any volume will do, preferably 500-1000 mL bag) (2) Pressure bag (3) Pressure transduction line (4)  Cable to go from transducerRead more

LVAD Poutpourri

This is the last segment of the LVAD-oriented series of pearls. There are a number of LVAD-related complications to be aware of. Disclaimer: I am an emergency medicine resident, not a heart failure fellow. This is my synthesis of a potpourri of LVAD-related complications and emergent management options. Power shortage: Make sure the pump hasRead more

Approach to the LVAD Patient: Part 2

There is a critical addendum to yesterday’s post, courtesy of Sam Schuberg. Patients with LVAD’s can go into dysrhythmias (VT, VF) despite the appearance of stability. Obtain an ECG on arrival in unstable patients with an LVAD. Thanks for reading the pearl, Sam. Now, on with today’s #TRPearl There are four parameters the LVAD monitor willRead more

Approach to the LVAD Patient: Part 1

LVAD management is an appropriate topic for a fellowship; not necessarily a TR pearl. But, resuscitating the sick LVAD patient is firmly within our scope of practice, and requires some basic knowledge of LVAD physiology. Enter rough sketch of a patient with an LVAD. Excuse my lack of artistic prowess:   There are a numberRead more

Listen for Hypoxia

The monitors at Mount Sinai (and at Elmhurst, and at most hospitals) allow you to add a tone to the pulse oximeter waveform (see: plethysmograph). The tone is a simple beep, but as the saturation drops so too does the frequency of that beep. By the time the saturation reaches 92%, the once reassuring beepRead more

Peds US PIV

“Hey doc, we can’t get a line on the kid in room 7, he’s going to need an US IV” is one of the last things I want to hear while working a peds shift. I’ve put US lines in teens, but they aren’t much different than adults in this regard. But what about youngerRead more

Calculous Cholecystitis: Early vs Delayed Cholecystectomy

Prompted by our M&M yesterday, below are the data surrounding delayed vs early cholecystectomy in patients with acute calculous cholecystitis.   TL;DR: Current evidence supports early cholecystectomy provided the patient is medically stable for surgery. All sources I found recommended admission. I could not find any sources that recommended discharge from the emergency department.   MetaRead more

EtOH Withdrawal: Ketamine, Precedex, and Other Pearls

Case: Unk-FrequentFlyer is rushed back to you in the cardiac room by Unk-Intern. He was found in the back corner of the B side shortly after 7am sign out. The patient is in florid alcohol withdrawal, combative, hallucinating, and of course does not have an IV. What’s your game plan?   Initial Sedation: This patientRead more