[BigBri.net] The official Brian Fields site

How [not] to Intubate

A common mistake - the ETT was 24cm at the lip.  I heard diminished breath sounds on the left, we pulled it back and taped it.  After the CXR came back, we rechecked - it was 28cm at the lip.  No wonder the vent was alarming high pressures.

ED Mnemonics

Here are a few mnemonics I picked up that helped me out...

HAD CLOTS: PERC Rule - Risk factors for PE
Hormone use
Age >50
DVT/PE History
Coughing Blood
Leg Swelling - Unilateral
O2 Sat < 95%
Tachycardia
Surgery/Trauma History - Recent

AMPLE: Important history items in trauma patients
Allergies
Medications
Past Medical/Surgical History
Last Meal/Last Menstrual Period
Events/EMS/Environment

PHAILS: Toxins that cannot be decontaminated with charcoal
Pesticides
Hydrocarbons
Acid/Alkali
Iron
Lithium
Solvents

DUMB BELSS: Cholinergic Toxidrome
Diarrhea
Urination
Miosis
Bronchospasm
Bradycardia
Emesis
Lacrimation
Salivation
Sweating

ME DIE: Differentials for Osmolar Gap
Methanol
Ethanol
Diuretics (Mannitol, Sorbitol)
Isopropanol
Ethylene Glycol

MUDPILES: Differentials for Anion Gap Acidosis
Methanol
Uremia
DKA
Paraldehyde
INH, Iron
Lactate
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents

AEIOU: Indications for dialysis
Acidemia
Electrolytes (Potassium)
Ingestion (Drugs)
Overload (Fluid)
Uremia

I STUMBLED: Toxins that can be removed by hemodialysis
Isopropanol
Salicylates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene Glycol
Depakote

AEIOU TIPS: Differentials for Altered Mental Status
Alcohol
Endocrine
Insulin
Opiates
Uremia
Toxins, Trauma, Tumor
Infection
Psychosis
Stroke, Seizure, Shock

Lara’s Neck

Lara was having some shoulder pain for a few weeks, and it wasn't going away.  I took her to see a doctor at the clinic, and she also had a few visits with a doc at school that did some manipulation, but she was still hurting.  We went back to the clinic for some injections, and got some xrays.  When the radiologist's report came back, there were some abnormal findings, so we ended up getting an MRI.  Lara has a few disks that are herniated dorsally (the arrows on the right).  Lots of people get these, and although it looks bad - it's usually no big deal.  Same thing with the Chiari Malformation (left arrow).  This is where the cerebellar tonsil protrudes through the foramen magnum at the base of the skull into the spinal canal.  Also not a huge deal.  The problem seems to be a combination of a reversal of the normal lordosis (the spine should have a natural backwards curve), and also a slight narrowing of the disk heights.  She also has some mild osteophytes (bone spurs).  All of these things are leading to a narrowing of the foramen that the nerve roots pass through as they exit the spinal canal.  C5 and C6 serve the back of the shoulder and also go into the brachial plexus - eventually leading to the median and radial nerve.  This is causing her some pretty intense pain and muscle spasms in her shoulder, as well as some tingling sensations down her arm.  Right now her doctor is recommending some conservative treatment including physical therapy and accupuncture.  We're really hoping that she will be able to avoid surgery.  Keep her in your thoughts and prayers.