Procedure legends?

[jw3600]

Am I crazy for still using it in mildly bradycardic, mildly hypotensive patients?

Why not epi or norepi +/- pacemaker?

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[turkeyjerky]

Why not epi or norepi +/- pacemaker?

I mean, I'm not wedded to it but I think most places have more familiarity with it than epi drips. Also, I'm talking about pt's w/ sinus brady, not a heart block--in that case I'd do a pacer.

 

[jw3600]

I mean, I'm not wedded to it but I think most places have more familiarity with it than epi drips. Also, I'm talking about pt's w/ sinus brady, not a heart block--in that case I'd do a pacer.

That's fair. I don't think dopamine is wrong- I just think dogmatically it's viewed as more right than it is. Cardiology loves it in crashing bradycardic patients so I feel a lot of EM people see that and reach for it. I feel like epi may eventually be seen as the optimal agent.

 

[Dr Mantis Toboggan]

Had a tough time getting a nice reduction in a couple patients with nasty trimall fractures this week. Any tips?

 

[thegenius]

Had a tough time getting a nice reduction in a couple patients with nasty trimall fractures this week. Any tips?

don't you just pull real hard and squeeze together after sedation? Ankles are seemingly not that hard.

 

[Mushdoc]

make sure the knee is bent to 90*

 

[bravotwozero]

don't you just pull real hard and squeeze together after sedation? Ankles are seemingly not that hard.

Trimal fx are super unstable anyway, high likelihood of suboptimal reduction. I know you don't strictly have to admit these, but I prefer to when I can.

 

[Dr Mantis Toboggan]

Trimal fx are super unstable anyway, high likelihood of suboptimal reduction. I know you don't strictly have to admit these, but I prefer to when I can.

Yes I always flex the knee and generally have pretty good luck getting the talus under the dome but these were some pretty terrible Weber C’s. Especially with all this ice and snow (I live in the SE) these people aren’t going anywhere.

 

[alpinism]

Had an eventful weekend.

Medics call in 30s female roughly 6 mos pregnant that went into cardiac arrest on arrival.

Arrives pulseless CPR in progress do abdominal US that shows fetus with heart rate.

Perform vertical section and find uterus with massive anterior fibroids.

No choice but to cut though to get the fetus but then starts bleeding profusely.

Pack the uterus but still bleeding heavily so decide to just ligate the uterine artieries.

Start massive transfusion and get mom back however codes again after a few minutes.

Run the code for over an hour and decide to finally call it due to futility.

The baby survived thankfully and still alive in the NICU after 24hrs.

 

[Dr Mantis Toboggan]

Had an eventful weekend.

Medics call in 30s female roughly 6 mos pregnant that went into cardiac arrest on arrival.

Arrives pulseless CPR in progress do abdominal US that shows fetus with heart rate.

Perform vertical section and find uterus with massive anterior fibroids.

No choice but to cut though to get the fetus but then starts bleeding profusely.

Pack the uterus but still bleeding heavily so decide to just ligate the uterine artieries.

Start massive transfusion and get mom back however codes again after a few minutes.

Run the code for over an hour and decide to finally call it due to futility.

The baby survived thankfully and still alive in the NICU after 24hrs.

Awesome job.

 

[The Knife & Gun Club]

Had an eventful weekend.

Medics call in 30s female roughly 6 mos pregnant that went into cardiac arrest on arrival.

Arrives pulseless CPR in progress do abdominal US that shows fetus with heart rate.

Perform vertical section and find uterus with massive anterior fibroids.

No choice but to cut though to get the fetus but then starts bleeding profusely.

Pack the uterus but still bleeding heavily so decide to just ligate the uterine artieries.

Start massive transfusion and get mom back however codes again after a few minutes.

Run the code for over an hour and decide to finally call it due to futility.

The baby survived thankfully and still alive in the NICU after 24hrs.

Holy crap to that entire story and strong work - that’s a solid save for the baby. But…you ligated the uterine arteries??? How did you even know how to do that?

I’d imagine it’s not that hard (the OBs do it all the time) but my god I can’t imagine even being able to find a vessel and be confident enough to ligate it in that kind of situation much less with CPR in progress.

 

[hopeful22213]

Holy crap to that entire story and strong work - that’s a solid save for the baby. But…you ligated the uterine arteries??? How did you even know how to do that?

I’d imagine it’s not that hard (the OBs do it all the time) but my god I can’t imagine even being able to find a vessel and be confident enough to ligate it in that kind of situation much less with CPR in progress.

Agreed- trying to think through how I'd approach ligating the uterine arteries. Don't think it's something I'd have tried and am curious how they went about doing so. Just watched the video linked with a demonstration and it doesn't seem like something I'd try in the ED (especially with a bloody field after dissecting through a fibroid). Great work @alpinism

 

[The Knife & Gun Club]

Also thanks for the necro-bump, I remember making this thread as an intern. Damn I was so much more jazzed about procedures in those days. Now I hear “difficult dialysis line” and just think of what a bloody time sink this is gonna be.

 

[bravotwozero]

Had an eventful weekend.

Medics call in 30s female roughly 6 mos pregnant that went into cardiac arrest on arrival.

Arrives pulseless CPR in progress do abdominal US that shows fetus with heart rate.

Perform vertical section and find uterus with massive anterior fibroids.

No choice but to cut though to get the fetus but then starts bleeding profusely.

Pack the uterus but still bleeding heavily so decide to just ligate the uterine artieries.

Start massive transfusion and get mom back however codes again after a few minutes.

Run the code for over an hour and decide to finally call it due to futility.

The baby survived thankfully and still alive in the NICU after 24hrs.

Did you have any assistance from OB?

Strong work!

 

[Apollyon]

Also thanks for the necro-bump, I remember making this thread as an intern. Damn I was so much more jazzed about procedures in those days. Now I hear “difficult dialysis line” and just think of what a bloody time sink this is gonna be.

Literally AND figuratively!

 

[Groove]

Man, I could seriously do with NEVER having a case like that. I also am very curious about any assistance you had... Was OB present at all? General surgery? Did you have residents with you?

I wouldn't know what the hell to clamp if I was looking for uterine arteries. I guess I'd just be taking forceps and clamping any vascular stalk that seemed to be leading to the uterus. Damn, dude. I'd need a stiff drink or three after that shift.

 

[alpinism]

Holy crap to that entire story and strong work - that’s a solid save for the baby. But…you ligated the uterine arteries??? How did you even know how to do that?

I’d imagine it’s not that hard (the OBs do it all the time) but my god I can’t imagine even being able to find a vessel and be confident enough to ligate it in that kind of situation much less with CPR in progress.

I've done a small number of crash sections while in rural Africa which definitely helped with doing the procedure.

But it's not that difficult and really all you need to do is clamp the base of the broad ligament of the uterus.

 

[alpinism]

Man, I could seriously do with NEVER having a case like that. I also am very curious about any assistance you had... Was OB present at all? General surgery? Did you have residents with you?

I wouldn't know what the hell to clamp if I was looking for uterine arteries. I guess I'd just be taking forceps and clamping any vascular stalk that seemed to be leading to the uterus. Damn, dude. I'd need a stiff drink or three after that shift.

I think OB and Peds showed up about 10 minutes into the procedure.

But I'm academics so had lots of assistance with 2 residents and 2 nurses.

 

[JacobMcCandles]

I've done a small number of crash sections while in rural Africa which definitely helped with doing the procedure.

But it's not that difficult and really all you need to do is clamp the base of the broad ligament of the uterus.


View attachment 377321

I would also have to pretend like I didn’t know who **** all over the floor.

 

[thegenius]

Man, I could seriously do with NEVER having a case like that. I also am very curious about any assistance you had... Was OB present at all? General surgery? Did you have residents with you?

I wouldn't know what the hell to clamp if I was looking for uterine arteries. I guess I'd just be taking forceps and clamping any vascular stalk that seemed to be leading to the uterus. Damn, dude. I'd need a stiff drink or three after that shift.

thats all you do. You find some bleeder...clamp it...tie it off. ****ing nutty. Who knows if it's a uterine artery and it doesn't really matter anyway at that point.

why was the patient in CPR in the first place? was it said?

 

[RustedFox]

I seriously wouldn't even know how to start this procedure beyond "cut in a line below the navel".

 

[thegenius]

I seriously wouldn't even know how to start this procedure beyond "cut in a line below the navel".

Need to start higher! Pts already dead. I remember being taught xyphoid-to-pubis.