Abdominal compartment syndrome and the logistics of measuring a bladder pressure

We do not encounter abdominal compartment syndrome often in the emergency department. With that said, this diagnosis enters our differential from time to time. Consider the patient with an active arterial bleed from a liver mass with large hemoperitoneum who is transferred from an outside institution for IR embolization. His abdomen is rock solid, and his lactateRead more

A not-so-comprehensive guide to assessing the right ventricle

Quick word: Demonstrating a normal sized RV does not rule out PE. With that said, if you have a hypotensive patient in whom you are concerned about massive PE, demonstrating the patient has a normal sized RV can lead you to consider alternate dangerous diagnoses. RV size The ratio of RV:LV chamber size should beRead more

BIPAP in SCAPE: (a few of) the hemodynamic effects of positive pressure ventilation

This pearl will be a brief rundown of the hemodynamic effects of BIPAP on the patient with sympathetic crashing pulmonary edema. This is an apical four chamber view with a dilated right ventricle – stretched vertically to the point of being almost unrecognizable – superimposed on the screen of a ventilator. Yes. BIPAP works forRead more

A Strange Pearl

As the title implies, this is a strange pearl. Imagine the following: You are in a can’t intubate/can’t ventilate scenario. The patient’s neck is large, and the landmarks are poor.  You cut through a depth of redundant tissue to get to the cricothyroid membrane, make your incision, insert your finger, and place a bougie. TheRead more

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