tag:blogger.com,1999:blog-1264812964585869968.comments2023-06-15T08:25:39.158-04:00EMOttawa - Emergency Medicine OttawaHans Rosenberghttp://www.blogger.com/profile/05133513056527108015noreply@blogger.comBlogger26125tag:blogger.com,1999:blog-1264812964585869968.post-53312086527581638822017-04-26T10:48:41.623-04:002017-04-26T10:48:41.623-04:00Hi Dr. Duggan, thanks for the comments and questio...Hi Dr. Duggan, thanks for the comments and questions. I'm going to try to get Dr. Rebecca brown to answer your first question.<br /><br />In regards to your comments regarding the re-enforced cannulas and commercially available kits, do you have any suggestions? Anything that you have experience with? I always find the balance between a "home-made" solution vs a commercial kit in those once in a lifetime situations a tough one. On one hand, most of the resources on this will tell you how to put together something that works, however you'll likely have to put it together at a very fast pace, nerve-wracking time. On the other, the commercially available kit will be easy to put together, however sometimes you have no idea where you put it since it's been a long time since someone last used it! =D<br />Would love to hear more about it, perhaps something our ED could consider purchasing.<br /><br />Please send us the link to your rounds once they are available!<br /><br />HansHans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-70965811848627751182017-04-25T18:52:56.684-04:002017-04-25T18:52:56.684-04:00A couple of comments/questions specifically for Pe...A couple of comments/questions specifically for Pediatric Surgical Airway:<br /><br />1. Low-pressure oxygen source for cannula cricothyrotomy. Can you be more specific about flow and/or pressure?<br />2. IVs have a high risk of kinking: there are re-enforced cannulas made for this rare situation situation<br />3. Attaching the end of an ETT to an IV catheter has a high risk of kinking at the skin There are other commercially available options available<br /><br />There are much better systems aside from the 'home made' ones suggested for this once-in-a-career emergency. We should be using them. Will be posting the Vancouver Island Trauma Rounds about pediatric surgical airway options from last week on twitter when it becomes available.<br /><br />There is also a section specifically addressing Paediatrics in the Canadian Airway Focus Group Guidelines 2013. <br /><br />Happy to discuss further if you like, thanks for bringing up and discussing pediatric difficult airway. Some good recent publications and a nice review of them. <br />All the best,<br />@drlauradugganAnonymoushttps://www.blogger.com/profile/18123858452489534935noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-78199736072863370992017-04-13T12:24:05.212-04:002017-04-13T12:24:05.212-04:00Hey Tim, thanks for your comment!
I agree that som...Hey Tim, thanks for your comment!<br />I agree that some of the views do come pretty close to helping make the diagnosis. In the case, the US operator was a very good resident but still in her training, especially when it comes to PoCUS, and they are strongly encouraged to be 100% sure of what they are visualizing. If there is any question then proceed with investigations that do not include PoCUS. As for McConnell's sign, I just had to look that up! I'm not one of the PoCUS gurus around here so I appreciate you teaching me something new.<br /><br />Thanks again for the input.Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-24314266487251309472017-04-13T03:05:28.219-04:002017-04-13T03:05:28.219-04:00Great case - nice job getting the diagnosis. I d...Great case - nice job getting the diagnosis. I do think you echo showed signs of PE. In your PDLX view, the RV cavity was at least the same size as the LV cavity and much bigger than the LA (should be the same in this view). On your apical 4 - even though the RV wasn't well visualized - there is a positive McConnell's sign at the apex of the RV. Thanks for sharing your great work. Tim Lewis, MD - Portland, ORAnonymoushttps://www.blogger.com/profile/07751904165257537493noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-5062347358439981362016-11-10T21:48:32.818-05:002016-11-10T21:48:32.818-05:00I agree as well, I like using glidoscope especiall...I agree as well, I like using glidoscope especially when junior residents are intubating but passing the tube might be quite difficult. Once u curve ur stylet appropriately you may pass it slightly beyond the tube and use it as a guide wire! That helped me on several occasions. Anonymoushttps://www.blogger.com/profile/17038902000418549554noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-73338462841693101012016-11-10T20:26:54.855-05:002016-11-10T20:26:54.855-05:00I also prefer DL, though I like the c-mac for teac...I also prefer DL, though I like the c-mac for teaching purposes. I'd say the one downside with learners and VL is that obtaining a view may feel easier, but passing the tube isn't always, and I've seen some pretty traumatic VL intubations because of this.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-22462520082346749352016-09-08T06:51:02.264-04:002016-09-08T06:51:02.264-04:00Great tips Hans. Great tips Hans. Muhammadhttps://www.blogger.com/profile/03502876166068166080noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-76731791986209174122016-09-06T00:33:13.210-04:002016-09-06T00:33:13.210-04:00Absolutely, the RN's keep you out of trouble a...Absolutely, the RN's keep you out of trouble and are the key to learning some of our ED procedures. Thanks for the extra tips!Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-37412258937915536192016-09-05T23:06:42.350-04:002016-09-05T23:06:42.350-04:00Love it Hans!
What about offer assistance to nurse...Love it Hans!<br />What about offer assistance to nurses - IV lines, catheters, etc.Gabriel Blecherhttps://www.blogger.com/profile/10768621544187856430noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-18441701708329316342016-09-05T19:18:07.711-04:002016-09-05T19:18:07.711-04:00Always recognize the knowledge of the senior nurse...Always recognize the knowledge of the senior nurses. They are your best friends.Anonymoushttps://www.blogger.com/profile/06003353285788605866noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-63408606983355092252016-08-01T23:39:58.337-04:002016-08-01T23:39:58.337-04:00We're so excited to have partnered with Dr. Th...We're so excited to have partnered with Dr. Thiruganasambandamoorthy to bring the Canadian Syncope Risk Score to the mobile & web application 'Calculate by QxMD', free for the global healthcare community.<br /><br />Access the tool here:<br />http://www.qxmd.com/calculate/calculator_383/canadian-syncope-risk-score-csrs<br /><br />- The QxMD Team<br /><br />QxMDhttps://www.blogger.com/profile/09844178286365237107noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-68891932199750926372016-03-21T12:35:07.189-04:002016-03-21T12:35:07.189-04:00Hey Juan, sorry for the delay answering. I've ...Hey Juan, sorry for the delay answering. I've personally started discussing it with the inpatient service that the patient is being admitted to whether they would like me to start Prednisone or not. I find given that it is not just one ED dose but 5-7 days as an inpatient then I want to make sure that what I do aligns with what will happen over the next week.Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-4062337836389722342016-03-03T05:56:45.582-05:002016-03-03T05:56:45.582-05:00Excellent article. Congratulations. Are you using ...Excellent article. Congratulations. Are you using steroids in pneumonia in light of this evidence?Anonymoushttps://www.blogger.com/profile/00410445551817012901noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-77076403177083364752016-01-28T10:53:06.984-05:002016-01-28T10:53:06.984-05:00Hi Jeff - great question. I agree with Hans' a...Hi Jeff - great question. I agree with Hans' answer above. I would just add that in relation to ketamine for sedation in the ICU, while I'm not aware of studies looking at using it for long-term sedation, some guidelines and position papers talk about concerns for increased rates of ICU delirium because of the Ketamine's disociative properties. Also, it would be more difficult to titrate ketamine to a desired level of sedation because it is not a traditional sedative.<br /><br />Thanks,<br />SebastianAnonymoushttps://www.blogger.com/profile/16816290783232135403noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-28136384765437059632016-01-27T20:28:16.985-05:002016-01-27T20:28:16.985-05:00Hi Jeff, thank you for your questions. In regards ...Hi Jeff, thank you for your questions. In regards to your comments here are my answers:<br />1) As far as I am aware there are no definitive studies that show negative patient oriented outcomes with the use of Etomidate in sepsis. However, there is the concern of adrenal suppression and that it may lead to negative patients outcomes. For this reason, I would suggest propofol as the agent to use in the septic patient. <br />2) I am not aware of any ICU literature on the use of Ketamine for long-term sedation in the ICU. I also discussed it with some ICU colleagues and they were not aware either. As for using Ketamine post-intubation from the ED to the ICU, it certainly seems like a reasonable choice as well.<br /><br />I will forward your questions to the author of the GR in case he has any other thoughts/comments.Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-19478577419167719602016-01-27T19:08:17.797-05:002016-01-27T19:08:17.797-05:00Quick question - Can you comment more on your reco...Quick question - Can you comment more on your recommendation for etomidate in post-intubation sedation? Last I had heard, there is a real risk of adrenal suppression after even a single bolus.<br /><br />Also, what about ketamine? It provides both dissociation and analgesia. Are you aware of any literature on long-term sedation with ketamine and ICU delirium?Jeffhttps://www.blogger.com/profile/08673077509608660564noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-6286897912346594422015-11-30T17:12:02.297-05:002015-11-30T17:12:02.297-05:00I like your Bottom Line, looks like we are in full...I like your Bottom Line, looks like we are in full agreement:<br />"Due to aforementioned biases and other factors mentioned, a one-hour protocol utilizing high sensitivity troponin T cannot be recommended at this time. External validation of this protocol along with a more explicit discussion of how the diagnosis of AMI is arrived at might allow for a rapid rule out in the future."Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-56147743604831272652015-11-30T16:48:28.680-05:002015-11-30T16:48:28.680-05:00Covered this paper on the SGEM http://thesgem.com/...Covered this paper on the SGEM http://thesgem.com/2015/09/sgem128-one-hour-ami-rule-out-harder-better-faster/Ken Milnehttps://www.blogger.com/profile/01146520362740204340noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-21652153688854734802014-10-19T22:36:37.390-04:002014-10-19T22:36:37.390-04:00Summary of Summary:
Unstable / A.Fib <48hrs / ...Summary of Summary:<br /><br />Unstable / A.Fib <48hrs / >3wks Therap. OAC: Cardiovert + D/C w/ OAC + Cardio.F/U <br /><br />A.Fib >48hrs or <3wks of Therap. OAC: Rate ctrl (<100: BB/CCB) + F/U w/ Cardio. <br /><br />OAC choice based on CHADS2 (w/ Age >= 65): <br />- 1+ = NOAC > Warfarin or (ASA+Plavix)<br />- 0+CAD = ASA<br />- 0 = nothing<br /><br />If Valvular AF (Mechanical valve / Hx Rheumatic MS): Warfarin > NOACAseem Bishnoinoreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-56741193968476517732014-10-07T12:04:50.138-04:002014-10-07T12:04:50.138-04:00Can you clarify your comment? What guidelines are ...Can you clarify your comment? What guidelines are you referring to and increased risk of what with ASA (bleeding, embolic events, etc?)? Thanks!Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-13502491182641137902014-10-07T11:24:03.654-04:002014-10-07T11:24:03.654-04:00Just confused with European guidelines suggesting ...Just confused with European guidelines suggesting INCREASED risk with ASA monotherapy in AF patients. Anonymoushttps://www.blogger.com/profile/12697575022734617273noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-48598386265399888892014-04-01T19:37:02.301-04:002014-04-01T19:37:02.301-04:00Thanks for the rink Teresa, will definitely check ...Thanks for the rink Teresa, will definitely check it out!Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-40979013086891504422014-03-31T23:44:44.806-04:002014-03-31T23:44:44.806-04:00Check out the ALiEM-AnnalsOfEM Global Journal Club...Check out the ALiEM-AnnalsOfEM Global Journal Club post on this: <br />http://academiclifeinem.com/aliem-annals-em-journal-club-targeted-temperature-management/<br /><br />Complete with discussion with the author!TChanMDhttps://www.blogger.com/profile/01630866549467436081noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-21686245121100962202013-07-27T10:14:06.270-04:002013-07-27T10:14:06.270-04:00No problem!No problem!Hans Rosenberghttps://www.blogger.com/profile/05133513056527108015noreply@blogger.comtag:blogger.com,1999:blog-1264812964585869968.post-84651683601413593322013-07-27T07:25:11.623-04:002013-07-27T07:25:11.623-04:00Nice blog Thanks for sharing.
Atraumatic Needles...Nice blog Thanks for sharing. <br /><a href="http://www.microsharpneedles.com/atraumatic-needles/atraumatic-needles.html" rel="nofollow"> Atraumatic Needles</a><br /><br />Anonymoushttps://www.blogger.com/profile/00349471659668066523noreply@blogger.com