Articles in "Procedure Blog of the Week"

Ultrasound-guided Central Venous Access: Are Landmarks a Thing of the Past?

by Rick Rutherford, M.D., FAAFP

Ultrasound has improved the safety and efficiency of a wide range of procedures including ultrasound-guided central line insertion

Do we really need to do a modified Allen’s Test before Radial Arterial Line Insertion?

by Joseph Esherick, M.D., FAAFP, FHM

This is further support that a pre-procedure modified Allen’s test is not a reliable predictor of ischemic complications for radial arterial line insertion and an abnormal Allen’s test should not be a contraindication to placing a radial arterial line.

Troubleshooting Difficult Intubations

by Joseph Esherick, M.D., FAAFP, FHM

Have you ever been able to see the vocal cords during direct laryngoscopy but you weren’t able to pass the endotracheal tube cuff beyond the cords? This occurs not too infrequently during endotracheal intubation and I am going to share a trick for this.

Video laryngoscopy has a superior first pass success rate compared with direct laryngoscopy in the ICU

by Joseph Esherick, M.D., FAAFP, FHM

Video laryngoscopy has a superior first pass success rate and lower rate of difficult intubations and esophageal intubations compared with direct laryngoscopy for ICU intubations.

Predictors of failed intubations using video laryngoscopy such as failed Glidescope intubations

by Joseph Esherick, M.D., FAAFP, FHM

The overall success rate for Glidescope intubations was 97%. Success for Glidescope intubation following direct laryngoscopy and success in patients with predictors of difficult direct laryngoscopy were 94% and 96%, respectively.

Optimal Location for Needle Decompression For A Tension Pneumothorax

by Hospital Procedures Consultants

Traditionally, needle decompression for the emergent treatment of a tension pneumothorax is the second intercostal space in the mid-clavicular line. This remains an option for needle insertion when you are treating a tension pneumothorax.

Early Goal Directed Therapy for Sepsis: No Longer?

by Rick Rutherford, M.D., FAAFP

The recently studied ProCESS study, has generated significant discussion about sepsis care and the ongoing need for early goal directed therapy for septic shock has been called into question.

Which cirrhotic patients are at high risk for bleeding during hospital procedures?

by Joseph Esherick, M.D., FAAFP, FHM

The standard tests to assess bleed risk do not accurately predict bleed risk in cirrhotic patients during bedside procedures.

Simulation Based Training for Central Venous Catheters

by Rick Rutherford, M.D., FAAFP

Balancing patient safety with trainee experience presents an ongoing challenge in medicine. Simulation based training has been proposed as a tool to improve the safety of bedside procedures, but has not been rigorously studied. This metaanalysis reviews the evidence available and evaluates whether simulation based training improves success rates for central venous catheter placement.

Does Cricoid Pressure Prevent Aspiration During Endotracheal Intubation?

by Joseph Esherick, M.D., FAAFP, FHM

There has always been some controversy about the utility of applying cricoid pressure (aka Sellick Maneuver) during rapid sequence intubation for the purpose of preventing aspiration. Theoretically, applying pressure on the cricoid cartilage posteriorly should occlude the esophagus against the vertebrae and therefore prevent passive regurgitation of gastric contents into the oropharynx.

MRI is useful to distinguish between residual clot versus acute recurrent DVT

by Joseph Esherick, M.D., FAAFP, FHM

Frequently the combination of a serum D-dimer level and compression ultrasound testing can differentiate between a residual venous clot and an acute recurrent DVT. However, sometimes the results are equivocal and in these situations an MRI direct thrombus imaging can help distinguish a residual clot from a recurrent DVT.

Simulation Based Training Improves Airway Management Skills

by Joseph Esherick, M.D., FAAFP, FHM

Simulation-based procedural training has been shown to improve procedural competence, safety, operator confidence and most importantly patient safety for every bedside procedure studied. Now, a new systematic review and meta-analysis confirms that simulation-based training in airway management improves procedural competence with direct laryngoscopy, endotracheal intubation, video laryngoscopy, laryngeal mask airway insertion, and King tube airway insertion.

Continuous capnography beneficial during mechanical ventilation

by Joseph Esherick, M.D., FAAFP, FHM

The American Association of Respiratory Care developed a clinical policy describing the benefit of continuous capnography during mechanical ventilation. This policy statement recommends continuous capnometry during mechanical ventilation

Can ultrasound predict volume responsiveness better than CVP?

by Rick Rutherford, M.D., FAAFP

“What is the patient’s volume status?” This question is commonly asked of medical students rotating through emergency departments and intensive care units across the country. The question is not, however, a simple question and has perplexed experienced clinicians for years. Further, we now know that volume status is not the right question as many who are volume overloaded still respond to fluids and others who appear volume depleted are not helped by additional fluids. Volume responsiveness, a more important clinical question, predicts the ability of fluids to improve clinical parameters such as cardiac output.

Performing Procedures on Patients Who Take Dabigatran, Rivaroxaban, and Apixaban

by Joseph Esherick, M.D., FAAFP, FHM

The drawback to these new oral anticoagulants is that there is no true antidote that can reverse the anticoagulant activity in the event that a patient develops a major hemorrhage or if they require emergency surgery or have a need for an invasive bedside procedure.

Procedural Sedation and Analgesia in the ED

by Joseph Esherick, M.D., FAAFP, FHM

The American College of Emergency Physicians (ACEP) just published a new clinical policy on procedural sedation and analgesia in the emergency department, which revised the previous policy from 2005.1 Procedural sedation is extremely common in the ED and can be performed safely and improve the patient and provider experience during difficult procedures.