Itching in the ED

 ·   · 

I think one of the most uncomfortable things in the world is being itchy. As a girl who has been taking an Allegra every single day since I was 8 years old, I thought we could do a bit of a deep dive into being itchy. 


The medical term for itch is defined as pruritus. Itches can be categorized into four big groups: Neurogenic, psychogenic, neuropathic, and pruitrioceptive causes. 


  1. Neurogenic itching: thought of as more of a systemic itch, the itch starts from the central nervous system as a result of other disorders of organ systems besides the skin. 

    1. This can be seen in patients with chronic renal failure, liver disease, hematologic and lymphoproliferative diseases and malignancies

    2. The pathophysiology behind this is not completely understood but it is not through a direct neuronal pathway and often improves with opioids 

    3. The thought behind this is that these pathologies cause increase secretion of intraspinal endogenous opioids which is why it is partially responsive to opioid antagonists 

  2. Psychogenic itching: usually a diagnosis of exclusion as the pathophysiology is not fully understood

    1. Usually presents with impulses to scratch or pick 

    2. Often associated with depression, OCD, anxiety, mania, substance induced psychosis, or somatoform disorders 

    3. Most well known is parasitosis: a specific delusion where patients believe there is some sort of insect or parasite living under their skin that they must scratch away 

  3. Neuropathic itch: caused by central or peripheral neurons that are damaged that inappropriately fires pruritic neurons causing the sensation of itching without any cutaneous etiology. 

    1. Often accompanied by paresthesia, hyperesthesia, hypoesthesia  

    2. The exact mechanism is unknown though thought to be due to specific damage due to the C fibers

  4. Pruritoceptive Itch: most common encountered. Usually generated by through inflammation thorough skin damage 

    1. This is a plug to TRULY look at a patient’s skin. If there is a rash besides urticaria or wheals, that sets you down an entirely different pathway, which is not the purpose of this discussion. This discussion is for good old, generalized, full body itching. 

    2. To avoid a true histologic lecture, the short of it is that itching is perceived through C fibers that are unmyelinated that are able to interact with keratinocytes in skin that react directly to pruritogens. 

    3. There is a theory that the nerves that perceive pain (nocireceptors) are able to block the sensation of itching therefore scratching does not relieve itching but rather it just blocks the sensation of itching providing temporary relief 

    4. Certain mediators are able to trigger the response of itching: 

      1. Histamine

      2. Triptase

      3. Interleukin 34

      4. Leukotrine B4

      5. Substance P


Okay- so now that we understand at a cellular level what is causing a patient to itch- now what? 

  1. As always the first step is determining if this is a systemic or local process: 

    1. Is this coming from a neurogenic perspective for example does this patient have renal failure or CKD and maybe this pruitius is a symptom of their worsening uremia? 

    2. Does this patient have a systemic rash, swelling of the oropharynx and recently ate a dish with peanuts that they have a known allergy to? Consider anaphylaxis and a hypersensitivity reaction and treat appropriately 

    3. Does the patient have an infectious reason for their itching? Are they covered in little insect bites? Do they have lice in their hair? Consider there are many little critters that will cause generalized itching 

  2. Stabilize the patient 

    1. Go back to your ABCs 

  3. Determine if there is a need for additional work up?

    1. Does this patient need labs to see if there is an infectious etiology or end organ damage? Consider a CBC, BMP, LFTs, lipase 

  4.  If truly just urticaria: treat!

    1. Non-pharmacological interventions:

      1. Moisturizer: avoid fragrances 

      2. Cool environments: cold packs, ice, cool shower

      3. Avoid irritants 

    2. Topical therapies: 

      1. Corticosteroids 

        1. Avoid the face and long term use 

      2. Capsicin

    3. Systemic therapies:

      1. Antihistamines: Benadryl (sedating) vs cetirizine/loratadine (nonsedating)

      2. Other more extreme causes with other systemic, noncutaneous causes can consider opioids, SSRIs, or immunosuppressants

      3. Corticosteroids
        I would be wary about starting any of these in patients outpatient or long term and encourage these patients to follow up outpatient


Well, now that we are all sufficiently scratching, heres at least a start to approaching that itchy patient in 22 hallway!

Garibyan L, Rheingold CG, Lerner EA. Understanding the pathophysiology of itch. Dermatol Ther. 2013 Mar-Apr;26(2):84-91. doi: 10.1111/dth.12025. PMID: 23551365; PMCID: PMC3696473.


Lerner EA. Pathophysiology of Itch. Dermatol Clin. 2018 Jul;36(3):175-177. doi: 10.1016/j.det.2018.02.001. Epub 2018 Mar 20. PMID: 29929590; PMCID: PMC6022764.


Macy E. Practical Management of New-Onset Urticaria and Angioedema Presenting in Primary Care, Urgent Care, and the Emergency Department. Perm J. 2021 Nov 22;25:21.058. doi: 10.7812/TPP/21.058. PMID: 35348101; PMCID: PMC8784078.


Nowak DA, Yeung J. Diagnosis and treatment of pruritus. Can Fam Physician. 2017 Dec;63(12):918-924. Erratum in: Can Fam Physician. 2018 Feb;64(2):92. PMID: 29237630; PMCID: PMC5729138.

 · 

Lions and tigers and TVPs Oh My!

 ·   · 

Today’s POTD comes inspired by a confusing kit, a rare procedure, and honestly a Strayer Voice Note. For our rising ones, our outgoing twos, and my loyal threes- this is a procedure that is not an everyday one and one that is worth spending our time talking about. So let’s dive in- 


TVP: Transvenous Pacer


Indications: unstable bradycardia (bradycardia + hypotension +/- AMS) or unresponsive to medication therapy 


A good first place to start is the TVP Checklist which can be found in the JIT (Just in Time) Resource and now attached to this email. 


I have attached a homemade video highlighting the usual trouble spots with our equipment/attaching the wires. I would recommend troubleshooting (aka connecting the wires/making sure everything fits PRIOR to poking the patient this way you can determine if someone needs to run up to CCU or for other materials). 


For all of the TVPs (grand total of maybe four) I have been a part of, I think there are two big issues, and here is my approach to troubleshooting: 

  • Connecting the wires: 

    • Do not lose your disposable adaptors

    • Make sure you really push the adaptors into the end of the wires, this will require brut strength and avoidance of all ultrasound gel 

    • Make sure these adaptors fit snug in your generator

      • Either directly into the ventricle (top) part of the generator

      • OR into the non-disposable adaptors into the extension cable 

    • Check this before you get started with poking the patient 

  • Floating the wire and getting capture

    • Make sure all of your wiring is secure, tight, and allows for electricity to flow appropriately

    • Balloon up going forward, balloon down with withdrawing 

    • Start looking for capture at 40 cm, do not push more than 50 cm 

    • A little bit of luck, a whole lot more patience 


Next, I want to highlight some of the equipment/big pictures: 


Preferred site of central venous access: Right internal jugular or left subclavian


Generator Box: 

  • These are found in the blue box located in the cardiology cabinet in resus 51. 

  • The generator box should be checked twice daily by the resus resident, though on occasion these will go upstairs to the CCU with a patient- in this case, the CCU should bring one down as an exchange. 


Extension Cable:

  • This may or may not come with an extension cable, also shown here but important to note that, you do not need this (but may want it). 

  • The extension cable allows you the have more slack on the wire, please see attached video on how to insert the extension cables and wiring to give you that increased slack 

  • Nondisposable adaptors that allow for our wires to be attached to the extension cable 


Wire: Parts of the wire:

  • Electrodes: two electrodes, one proximal end and one distal end; the reusable 2 mm adapters we have in our kit that insert into the electrodes are EXTREMELY difficult to fully push into the end of the wires which may be responsible for difficulty with capturing, please make sure these are fully inserted 

  • Balloon: on the opposite side of the electrodes, is the part that enters the heart, check for an air leaks prior to entering into the patient

  • 3 way stop cock: used to inflate the balloon, use special syringe for this (see below)


Plastic Sheath: Unfortunately there is a correct way to put this on and an incorrect way 

  • This MUST be threaded over the wire prior to inserting the wire

  • Thread the wire through the smaller cap of the sheath, the larger cap is the piece that connects to cordis 


Cordis/Cordis Cap: 

  • Regular run of the mill cordis 

  • I am sure there is a more formal name, but I think of it as a party hat for the cordis that goes on top and tucks in. This allows the wire to pass through the cordis, and lock into place with the protective sheath on top 


Balloon Syringe: 

  • Specialized syringe that gives a set amount of air to avoid overfilling the balloon


Battery:

  • The generator box relies on 9V batteries. Please check that your generator has a functioning battery before you use it, if you need another battery both the charge nurses (south and north) have batteries they can give you to replace 


Just some general reminders about TVPs: 

  • Mode/Sensitivity: We are using ventricle pacing 

  • Rate: 

    • Usually chose between 60-100 bpm

    • If a patient is being transcutaneously paced while you are placing the TVP, set the two pacing systems to a different rate therefore you can tell when a patient is being paced by which system. 

      • Example: if your patient is being transcutaneously paced, set this to 70 bpm but your TVP to a rate of 80, this way when you are watching the monitor if the patients HR all the sudden becomes 80, you know that they are now being transvenously paced

  • Output: 

    • Maximum: 20-30 mA


Simplified Review of the Steps: 

  1. Place the Cordis 

  2. Place sterile sheath over pacing wire in the correct orientation 

  3. Assure generator is on, with settings at appropriate levels 

  4. Inflate the balloon as soon as the wire is inserted past the level of the Cordis sheath (approximately 15-20 cm), lock the balloon inflated using the syringe 

  5. Advance the wire: 

    1. Floating: fast and smooth movements 

    2. Inflate the wire when advancing

    3. De-inflate the wire when withdrawing 

  6. Wire should be at least 40 cm deep without capture, do not advance beyond 50 cm 

  7. Capture will look like: 

    1. LBBB on EKG or monitor 

    2. Manual pulse at the desired rate 

  8. Identify the capture threshold

    1. Aka decrease the threshold until you use capture, use a capture right above that 

  9. Identify appropriate output

    1. Aka 2-3x the threshold determined above 

  10. Secure the wire 

    1. Suture in place

    2. Sterile dressing

    3. Tape the generator to somewhere STABLE (aka not in a place that can accidentally be ripped off by the patient, family, or anyone)

  11. Get confirmation on EKG and CXR 

  12. Call the CCU  


Couple of things are attached to this email and below: 


EMRAP’s How to place a TVP: 

https://www.youtube.com/watch?v=00-T8PcbStE&t=18s

A useful video going through the steps


Kings County’s Review of Troubleshooting TVPs: 

https://blog.clinicalmonster.com/2021/04/15/transvenous-pacemaker-placement-and-troubleshooting/


-Also attached is the JIT TVP Checklist

-A homemade video highlighting some of our equipment and its pitfalls 


Hopefully this did not confuse anyone more, I am thinking we will soon need a video with our equipment to enter the JIT Folder but for now, hopefully this helps!


Until next time!

Moayedi S, Torres M. Cardiac Pacing. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recMOAnz71cN3N0OF/Cardiac-Pacing#h.i374rmm1hkxn. Updated November 3, 2023. Accessed March 19, 2025.


https://blog.clinicalmonster.com/2021/04/15/transvenous-pacemaker-placement-and-troubleshooting/


https://www.emra.org/emresident/article/device-series-tvp



 · 

Feel Good Friday: Contact Center

 ·   · 

Today we have a special edition Wellness POTD for a little Feel Good Friday. Over the next few weeks, I am going to highlight different parts of our Emergency Department team and today we are going to get started with our beloved Contact Center!


Today, March 14th, 2025 celebrates our Emergency Department Contact Center’s 11th Anniversary. I got the opportunity to stop by, see where the action happens and talk to some of our beloved friends on the other side of the phone and wanted to share the magic with you. 


Our ED Contact Center is located at 919 49th Street in a shared space with the radiology contact center. The department will be moving in the next few months closer to the HR Department in a newer part of the hospital. 


The Contact Center is made up of 14 different employees who work 8 hour shifts 24/7. The magic starts with someone putting in an order to contact someone else. This prints out a physical slip with the information in place (see below picture for slip maker!). The contact center team member calls or pages the desired contact, gets this person on the phone, then calls the team member who called in the slip and connects the two callers. These employees have all of the residents Avaya extensions memorized and can often tell exactly who it is just with a simple hello! When I stopped by today, I had the opportunity to talk to some of our favorites and wanted to highlight each of them: 


Yocasta Santana- 

Yocasta has been working at the ED Contact Center for the last 9 years after leaving the fashion world, previously working for Prada. Yocasta loves Maimonides for lots of reasons but specifically mentioned that she feels appreciated in her role and feels there are lots of opportunities to grow within the Maimonides system. She enjoys being challenged regularly and has loved the journey she has taken to get where she is now. Yocasta can be found picking your calls up with headset in place, ready to find whoever you need!


Alyssa Wheeler- 

Alyssa started working at Maimonides in the Contact Center two years ago, previously she was working with children in summer camps and in afterschool programs. Alyssa also loves the opportunities to grow that Maimonides offers and is working to prepare her application for nursing school. Alyssa wants everyone to know that it isnt always easy to get someone on the phone and she's constantly hammer paging/calling someone to get them to speak with our ED Team. Alyssa reports she initially was a headset person but has converted to being a landline, handheld phone girlie. 


Kevin Bourne- 

Kevin is a contact center OG. He has been at Maimonides for almost 15 years! He started working in the physical ED as a clerk, moved into communications and sat where the current patient rep sits! Kevin has every resident’s extension memorized and rumor has it at the holiday parties can call you out by number. Kevin’s favorite part of Maimonides is the people, he said he has the utmost faith and belief in the people who work hard for this hospital. Kevin says that he envies the old days and misses being in the thick of the action and being a part of the work flow in the ED. Kevin prefers to speak to us on speaker phone and is a hard no to the headset. 


Consider this our formal thank you and happy anniversary to the best of the best, the angels who somehow find whatever PMD I page at 3 am on a Friday overnight southside shift. Though I got to only stop by and meet a handful of friends from the contact center - this is really dedicated to all of the contact center staff- we are so grateful for all that you do!


If you were looking for it- this is your sign- call x37444 say a happy anni, a big thank you, or stop by and see our friends in the contact center!

 ·