POTD: IDSA Guidelines for CT before LP

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POTD: CT prior to LP

 

Happy Sunday everyone, hope everyone has had a good weekend. Your second favorite teaching resident here with a new  POTD. This one brought to you by a conversation I had with doctors Duo Xu and Amish Aghera, inspired by when I had to go to the sim center and forgot my ID behind the lumbar puncture model.

 

Often it is a mantra to obtain a head CT before LP to assess for a process that increases intracranial pressure that could potentially cause highly morbid and dreaded brain herniation.  However, a delay in care for a patient with suspected meningitis can be devastating.

Below are some guidelines developed by the IDSA for these situations

 

IDSA Guidelines for patients for patients who require a CT before LP:

 

  • Patients who are immunocompromised (HIV infection, taking immunosuppressants, or after transplantation)

  • Patients with a history of central nervous system disease (mass lesion, stroke, or focal infection)

  • Patients with new onset of seizure within one week of presentation

  • Patients with papilledema on fundoscopy

  • Patients with an abnormal level of consciousness

  • Patients with a focal neurologic deficit

 

For those who prefer visual representation (see the link below for inquiries about recs beyond timing of LP):

 



 

Research shows that physicians are not particularly adherent to these guidelines, (a study from Houston in the link below showed 60% adherence), but remembering them can save a patient from unneeded radiation, will prevent a delay of treatment, and can help lead to a more efficient and appropriate disposition.

 

Enjoy the beginning of Thanksgiving week everyone

 

Mak Sarich MD                                                                                                                                          

 

References:

https://knowledgeplus.nejm.org/blog/suspected-bacterial-meningitis/

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POTD: Escharotomy

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This POTD is inspired by a rosh review question I got wrong recently. This rare ED procedure is important to understand but not that common so here’s a refresher!


What is an escharotomy?

  • Eschar is dried dead skin/tissue after a burn or infection (shown above)

  • An escharotomy involves incising through burnt skin to release eschar 

Why perform it?

  • Circumferential, full-thickness (sometimes partial thickness) burns that produce a splinting/tourniquet effect that could impair limb circulation or respiratory muscle movement

  • Eschar is stiffer than skin -- restricts movement

  • Also with fluid resuscitation and local edema, increased risk of increased compartment pressures when fluid builds up beneath eschar

Some physical exam findings that suggest need for escharotomy:

  • Limbs with the 6 P’s: 

    • Pain, paresthesias, poikilothermia, pallor, paresis, absent pulse

  • O2 sat < 95%

  • Decreased/absent doppler signal in affected limb

  • High compartment pressure

  • Any compromise in respiratory function or hemodynamics

Equipment

  • Local anesthetic +/- sedation

  • Sterile prep and drapes

  • Scalpel

  • Marking pen

  • Cautery device

Positioning

  • Supine

  • Upper limbs supinated

  • Lower limbs in neutral position

  • Mark incision lines then prep skin

  • Mark areas with at-risk structures such as ulnar nerve (@ medial epicondyle of humerus) and common peroneal nerve (@ neck of fibula)

Technique

  • Make incisions in longitudinal axis with scalpel or cutting cautery, using coagulation cautery for hemostasis along the way

  • Perform in stepwise fashion, reassessing the body part along the way (one incision, recheck, etc)

  • Ideally incision should extend b/w 2 unburnt areas and go down to (but not including) muscle fascia

  • Should go proximal to distal

  • Dress in alginate dressing 

  • Where to make the incision depending on location:

    • Finger: midaxial line 

    • Upper limb: medial/ulnar incision should be anterior to medial epicondyle (avoid ulnar nerve)

    • Lower limb:

      • Medial incision should be posterior to medial malleolus (avoid great saphenous vein or saphenous nerve)

      • Mid lateral incision should curve around fibular neck (avoid common peroneal nerve)

    • Chest: breastplate incision - along anterior axillary line in both sides, connected by 2 transverse incisions in upper chest and upper abdomen


Happy cutting! And don’t forget to consult your local burn specialist prior to this procedure.

Reference

https://www.ncbi.nlm.nih.gov/books/NBK482120/
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POTD: Procedure vids - Dual lumen midline & cavity drainage catheter

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Today you get TWO POTDs, and they are both procedure videos.

The first shows placement of the dual lumen midline. The one that no ones likes. This is NOT the powerglide.

Midlines are placed in the ED for a few reasons, such as for pressor infusion when you don't want to place a central line, to replace a patient's long-term midline for at home medication infusions, or when medicine asks you very nicely if you can please place a midline for them.

Here's the link to the video, demonstrated by Joann with help from Sim Master Duo:

https://youtu.be/ggIq9gYnPTk

The second demonstrates how to use this percutaneous cavity drainage catheter set by Arrow, which is currently the stand-in for our Wayne pneumothorax kits for pigtail placement. Apparently our usual pigtail kits are on backorder for now, so this is what we have.

Here's the link to the video, demonstrated by Mak:

https://youtu.be/kG5DMeKpWbE

Enjoy!

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