Can You ID this Seldom-Needed, but Essential EM Tool?

carly buckingham · February 12, 2018 ·

1) Name that tool. This device goes by the name “Compass.” It is similar to a model manufactured by Stryker, which is also highly distributed, but tends to have less accurate readings than the Compass.

2) Why do you need it?

It’s most critical function is for measurement of compartment pressures (it has other uses, as well, such as measurement of opening pressure for LP). Although compartment syndrome is really a clinical diagnosis (remember your “6 P’s”), you or your consultants may want to use this device for diagnostic confirmation before fasciotomy.

3) How does it work?

Your Compass will likely come in a kit containing the necessary accessories for its use. The kit stocked in our ED looks like this:

Ready to confirm your diagnosis? Prep skin and find your sterile gloves. Remove the caps from the ports on both ends of the Compass monitor. Attach an 18 G needle to the longer port. Attach a syringe with sterile water to the other and inject ~ 0.5 cc to remove air in the monitor. Hold down the red button on the side of the monitor until the reading “00” appears. Now you’re set to go.

For a review of how and where to check compartments, check out this video by EM:RAP (which gives instructions for the Stryker model, but the same principles apply for both devices).

https://www.youtube.com/watch?v=XXp0EtKtlF8

Finally, remember the number 30.

For the diagnosis of compartment syndrome:

Delta Pressure (= diastolic BP - compartment pressure) < 30

Or an absolute compartment pressure > 30

Want to learn more?

https://www.youtube.com/watch?v=_J4Bdssj4kk

https://lifeinthefastlane.com/trauma-library/basics/compartment-syndrome/

https://emedicine.medscape.com/article/307668-overview

POTD: Can You ID the Indication for this Seldom-Needed, but Essential EM Rescue Med?

carly buckingham · February 12, 2018 ·

It’s not propofol. This milky-white substance is Intralipid solution. There are plenty of uses for intralipid infusions in medicine; for the purpose of this blog, take note that we are discussing the 20% solution.

1) So why do you need it?

For reversal of local anesthetic-induced systemic toxicity (aka “LAST”) manifested as either: cardiac arrest that is refractory to standard ACLS therapy, or neurotoxicity manifested as status epilipticus.

It’s use has also been suggested in algorithms for reversal of cardiotoxicity caused by numerous other lipophilic drugs, such as TCAs and beta-blockers. However, the optimal administration and dosage recommendations for use in PO ingestions are not clear yet... so keep your ears open!

2) How does it work?

Proposed mechanism for reversal of anesthetic-induced toxicity: well, it’s again not quite clear, but the term “lipid sink” is thrown around quite a bit (see links at bottom of page for more info).

Somewhat easier to figure out is how to give it. As a general rule, for a 70 kg adult in cardiac arrest:

Give a 70 mL bolus over 1 minute. Wait 3 minutes. Repeat x 2 if no response to initial bolus (hopefully by now you’ve achieved ROSC). Then hang the bag and give the remainder as an infusion over 15 minutes.

The suggested max dose is 8mL/kg, which for a 70 kg adult is conveniently just over the size of a 500ml container in which it is usually packaged.

Want to learn more?

http://rebelem.com/local-anesthetic-systemic-toxicity-last/

http://www.thepoisonreview.com/2015/06/09/how-lipid-rescue-therapy-works-its-more-than-just-a-sink/

https://www.ncbi.nlm.nih.gov/pubmed/19845549

http://lipidrescue.org

POTD: Can You ID this Seldom-Needed, but Essential EM Tool?

carly buckingham · February 11, 2018 ·

1) Name that tool.

Blakemore Esophageal tube. You may also see it's close relatives, the Minnesota tube and the Linton tube, out in practice. There are slight variations between the structures of these three devices, but they all serve the same purpose. Here is a schematic of how the Blakemore tube, once placed, functions to tamponade hemorrhage.