Acute Mastoiditis

Acute mastoiditis is the most common, and usually the initial, complication of AOM. The diagnosis can be confusing due to differing uses of the term “mastoiditis”. Radiographic mastoiditis simply refers to fluid in the mastoid air cells, which can occur with any AOM due to communication between the middle ear and the mastoid air cells. However, acute mastoiditis for the EP involves clinical evidence of mastoid inflammation such as erythema, tenderness to palpation, bogginess, and swelling over the mastoid bone. A clinical diagnosis of acute mastoiditis necessitates treatment with IV antibiotics with a consideration for tympanostomy and mastoidectomy. Occasionally, a CT scan with IV contrast should be considered to evaluate for additional complications such as abscess.

Peritonsillar abscess aspiration technique

Build a kit similar to the butterfly phlebotomy setup (above drawing).

  • Attach IV extension tubing to the spinal needle.
  • Attach the other end of the IV tubing to the syringe.
  • Ask the assistant to apply negative pressure on the syringe once you have penetrated the oral mucosal surface.
  • Now you can focus on just directing the needle to the appropriate area.

Tranexamic Acid

Tranexamic AcidTXA is a safe, inexpensive medication that prevents fibrin breakdown.  In traumatic bleeding, it conveys a significant mortality benefit with an impressive NNT for mortality between 7 and 67, depending on injury severity, without apparent serious safety issues.  This benefit is associated with early administration.  TXA should not be given more than three hours after injury as it may increase mortality after this timeframe.  It appears to have equal benefit in a variety of trauma practice environments.

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ACLS Revision: Symptomatic Bradycardia

ACLS Revision: Symptomatic Bradycardia

ATROPINE

Atropine administration should not interfere with cardiac pacing.  If there is a favorable response to atropine, the conduction abnormality is likely in the AV node. However, if the escape rhythm is originating at or below the bundle of His, there is unlikely to be a response to atropine as the more distal conducting system is not as sensitive to vagal stimulation. Response to atropine can be predicted by looking at the QRS morphology on a 12 lead ECG.  If the AV block occurs in the AV node or the Bundle of His, the escape rhythm will have a narrow QRS and will likely respond to atropine. Conversely, if the AV block occurs below the bundle of His, the escape rhythm results in a sub-junctional escape rhythm which has a wide QRS and is unlikely to respond to atropine. NOTE: Because atropine can increase cardiac demand, it is contraindicated in patients with complete heart block secondary to myocardial infarction or ischemia.

TRANSCUTANEOUS PACING

  1. Pad Placement and set up: Recommended pad placement for the best capture is anterior/posterior, as shown below. The positive pad is placed posteriorly to the left of the spine, beneath the left scapula. The negative pad is placed anteriorly between the xiphoid process and the left nipple.

Pic 2 Pad Placement

Alternatively, the pads may both be placed anteriorly, with the negative electrode placed in the V6 position and the positive electrode to the right of the sternum, under the clavicle.

Pic 3 Pad Placement

  1. Select Mode: Select the pacemaker button on the box and choose between fixed and demand modes. Fixed mode means that the pacemaker will fire at whatever rate you choose, regardless of the patient’s intrinsic rhythm. Demand mode will sense the patient’s intrinsic rhythm and pace only if needed. Most often you will start in fixed mode.
    • NOTE: If in demand mode, the leads should be placed for continuous ECG so that the pacemaker can sense the patient’s intrinsic rate to pace accordingly (double set up). This prevents the “R on T” phenomenon.
  1. Set rate and output: The initial pacing rate should be set to 60 bpm with the current set to 30 milliamperes (mA). Beware that initially, pacemaker spikes may be visualized without resultant cardiac depolarization. The current can be increased by 5-10 mA at a time until capture is seen as a definite QRS complex and T wave following each pacemaker spike (electrical capture).  Once capture is achieved, check the patient’s pulse (mechanical capture) and correlate with the pulse oximeter, blood pressure  and clinical signs (physiological capture) to ensure that a perfusing rhythm is present.  Final output should be set to 10% above threshold level to ensure continued capture. Human studies have shown that the average current necessary to achieve capture is between 65-100 mA in unstable bradycardias and about 50-70 mA in hemodynamically stable patients.

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Fun Medical Trivia

Fun Medical Trivia

  1. Which tyre company invented the surgical glove?
  2. What is keraunoparalysis?
  3. Which node sits in the “seat of the devil“?
  4. What was described as “a night of Venus and a lifetime of Mercury“?
  5. That word’s on the tip of my tongue…. What is the word for this experience (its not thingamajig)?

Size does matter

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If you want to get big water into your patient, observe the following recommendations:

  1. Gauge is king. Choose the fattest tube you can stick into the patient.
  2. When it comes to catheter length, it’s not the size… it’s how you use it. Shorter catheter lengths mean less resistance.
  3. Consider plugging your drip set directly into the catheter hub instead of using a needle-free adapter or saline lock. The aforementioned study reports significant loss of flow through these types of connectors.
  4. Optimize the pressure difference between the bag and the vein. Place the bag high above the patient and use a compression sleeve, if indicated.

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Trauma in the 3rd Trimester

Trauma in the 3rd Trimestre

  • Any resuscitative efforts geared toward optimizing the medical management of the pregnant mother will optimize the fetal well-being.
  • Provide high oxygen flow to compensate for the pregnancy-based predisposition toward hypoxia.
  • Aggressive IV fluids administration, since blood pressure and pulse are not a reliable indicator of impending cardiovascular collapse during pregnancy.
  • Avoid having the gravid uterus compressing the inferior vena cava with left-sided upward tilt, wedge displacement, or manual displacement.
  • Avoid femoral lines that could be impeded by a gravid uterus.
  • Administer prophylactic dose of Rhogam to all Rh-negative mothers with abdominal trauma.
  • Peri-mortem C-section should be considered within 5 minutes of witnessed cardiac arrest.